OB Exam 2

The nurse assess a 15-hour old infant and finds jaundice. What is the priority action the nurse needs to take? 1. Continue with the normal newborn exam 2. Notify the HCP of the finding 3. Provide an extra feeding for the infant 4. Wait and assess the skin color when the infant is over 24 hours old

2; before 24 hours is pathologic so you need to notify bc it is not normal. The HCP can give then orders of what to do next. After notifying, then I can continue my exam. -providing an extra feeding would help more with physiologic jaundice, but also you don't want to just wait.

After reading the EHR, what nursing actions are most indicated? 1. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. 2. Place a pulse oximeter and contact the HCP for a prescription to draw blood cultures. 3. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis. 4. Draw a CBC with differential and feed the infant.

2; the ruptured membranes can make mom infected, and that can cause baby to also be infected. We need to get an O2 reading and get order for culture to see if we have infection 1- need to do something now bc baby is having respiratory difficulties 3- that does not automatically mean baby has to go to NICU 4- not just going to draw this

What is the infant's 1 minute Apgar score?

8 (on a scale off 0-10) -we need to know the Apgar chart

Immediate Interventions

Airway maintenance -Most secretions are moved by gravity and brought by the cough reflex to the oropharynx to be drained or swallowed or wiped away -infant has excess mucus in the respiratory tract, the mouth and nasal passages can be gently suctioned with a bulb syringe -auscultate the infant's chest with a stethoscope to determine if crackles or inspiratory stridor is present -Fine crackles may be auscultated for several hours after birth, especially in neonates born by cesarean -If the bulb syringe does not clear mucus interfering with respiratory effort, mechanical suction may be used -you will also dry the baby really good for temp and it stimulates our respirations. When drying the baby, we also put a hat on their head and put a diaper on. We will. be checking the O2 sat- it is normal for it to be in the 60's when you first put it on. It can take up to 5 to 10 min for it to get up to 85 and 90's. Maintaining an adequate oxygen supply -Clear airway -Effective establishment of respirations -Adequate circulation, perfusion and cardiac function -Adequate thermoregulation -Abnormal Newborn Breathing -Bradypnea (≤30 respirations/min) -Tachypnea (≥60 respirations/min) -Abnormal breath sounds: coarse or fine crackles, wheezes, expiratory grunt -Respiratory distress: nasal flaring, retractions, stridor, gasping, chin tug -Seesaw or paradoxical respirations -Skin color: cyanosis, mottling -Pulse oximetry value: <95% Maintaining body temperature -ideal method for promoting warmth and maintaining neonatal body temperature is early skin-to-skin contact (SSC) with the mother -naked infant is placed prone directly on the mother's chest -then covered with a warm blanket and a cap is placed on the infant's head -distinct short- and long-term benefits: -temperature stabilization -reduced crying -improved breastfeeding initiation and duration -maternal attachment If the infant does not remain skin-to-skin with the mother during the first 1 to 2 hours after birth: -the thoroughly dried infant under a radiant warmer or in a warm incubator until the body temperature stabilizes -thermistor probe (automatic sensor) is usually placed on the upper quadrant of the abdomen immediately below the right or left costal margin (never over a bone). A reflector adhesive patch can be used over the probe to provide adequate warming. This probe is designed to detect minor temperature changes resulting from external environmental factors or neonatal factors (peripheral vasoconstriction, vasodilation, or increased metabolism) before a dramatic change in core body temperature develops - servo-controller adjusts the temperature of the warmer to maintain the infant's skin temperature within the preset range. The sensor needs to be checked periodically to make sure it is securely attached to the infant's skin -temperature of the newborn is checked every hour (or more often as needed) until the newborn's temperature stabilizes -heat loss must be avoided or minimized for the newborn; therefore, examinations and activities are performed with the newborn under a heat panel -initial bath is postponed until the newborn's skin temperature is stable and can adjust to heat loss from a bath -infant should be warmed gradually because rapid warming can cause apneic spells and acidosis •Eye prophylaxis -prophylactic agent in the eyes of all neonates to prevent ophthalmia neonatorum or neonatal conjunctivitis, which is an inflammation caused by sexually transmitted bacteria acquired during passage through the mother's birth canal - targeted primarily toward preventing infection from Neisseria gonorrhoeae -infection can lead to blindness -Erythromycin 0.5% ophthalmic ointment, tetracycline 1% ointment, and silver nitrate 1% solution are considered effective as preventive medications, although silver nitrate and tetracycline are not available in the United States -usually administered within the first hour after birth •Vitamin K administration -intramuscular (IM) injection of 0.5 to 1 mg of vitamin K is given soon after birth to prevent hemorrhagic disease of the newborn •Promoting parent-infant interaction -Early contact between mother and newborn can be important in developing future relationships; it also has a positive effect on the initiation and duration of breastfeeding -Rooming-in during the hospital stay promotes parent-infant interaction -Produces physiologic benefits for the mother and neonate: -Maternal levels of oxytocin and prolactin rise with early breastfeeding -Developing active immunity begins as the infant ingests antibodies from the mother's colostrum

Discharge Planning and Teaching

Education is key in this entire process, esp. if it is a firs time mom (breastfeeding, changing diaper, etc.) -as they are about to go home, they need to know when to call the doctor, etc. -all babies need to go see the doctor within the first week (2 days for vaginal, 72 hours for c section?) Temperature The causes of changes in body temperature and the body's response to extremes in environmental temperature -Ways to promote normal body temperature, such as dressing the infant appropriately for the environmental air temperature and protecting the infant from exposure to direct sunlight -Use of warm wraps or extra blankets in cold weather -Technique for taking the newborn's axillary temperature, and normal values for axillary temperature -Signs to be reported to the primary health care provider such as high or low temperatures with accompanying fussiness, lethargy, irritability, poor feeding, and excessive crying Respirations -Normal variations in the rate and rhythm of respirations -Use of the bulb syringe -Steps to take if the infant appears to be choking Need to protect the infant from: -Exposure to people with upper respiratory tract infections and respiratory syncytial virus -Exposure to secondhand tobacco smoke -Suffocation from loose bedding, water beds, and beanbag chairs; drowning (in bath water); entrapment under excessive bedding or in soft bedding; anything tied around the infant's neck; poorly constructed playpens, bassinets, or cribs -Sleep position: on back when put to sleep -Notify the health care provider if the infant develops symptoms such as difficulty breathing or swallowing, nasal congestion, excess drainage of mucus, coughing, sneezing, decreased interest in feeding, or fever Feeding patterns -Nurses instruct parents about infant feeding and provide assistance based on whether they have chosen breastfeeding or formula feeding Elimination -Awareness of the normal elimination patterns of newborns helps parents recognize problems related to voiding or stooling -Color of normal urine and number of voidings to expect each day -Changes to be expected in the color and consistency of the stool (i.e., meconium to transitional to soft yellow or golden yellow) -number of bowel movements, plus the odor of stools for breastfed or bottle-fed infants -Formula-fed infants may have as few as one stool every other day after the first few weeks of life; stools are pasty to semi-formed -Breastfed infants should have at least three stools every 24 hours for the first few weeks. The stools are looser and resemble mustard mixed with cottage cheese; the odor is less offensive than stools of infants who are formula fed Positioning/holding -supine position for sleep during the first year of life to prevent sudden infant death syndrome (SIDS) -Infants should lie on a firm surface, specifically on a firm crib mattress covered by a fitted sheet -materials such as bumper pads, comforters, quilts, pillows, sheepskins, or stuffed toys should not be placed in the crib -When the infant is awake, "tummy time" can be provided under parental supervision so the infant can begin to develop appropriate muscle tone for eventual crawling -Care must be taken to prevent the infant from rolling off flat, unguarded surfaces -infant is always held securely with the head supported because newborns are unable to maintain an erect head posture for more than a few moments Rashes -dermatitis or skin inflammation appears as redness, scaling, blisters, or papules -contribute to diaper rash including infrequent diaper changes, diarrhea, use of plastic pants to cover the diaper, a change in the infant's diet such as when solid foods are added, or when breastfeeding mothers eat certain foods -Diapers should be checked often and changed as soon as the infant voids or stools -Plain water with mild soap, if needed, is used to cleanse the diaper area; if baby wipes are used, they should be unscented and contain no alcohol -skin should be allowed to dry completely before applying another diaper. Exposing the buttocks to air can help dry up diaper rash. Because bacteria thrive in moist, dark areas, exposing the skin to dry air decreases bacterial proliferation -most cases resolve within a few days with simple home treatments -rash on the cheeks can result from the infant's scratching with long unclipped fingernails or from rubbing the face against the crib sheets, particularly if regurgitated stomach contents are not washed off promptly -skin begins a natural process of peeling and sloughing after birth Clothing -dress the child for the environment as they dress themselves, adding no more than one layer more than they would be wearing as adults -cap or bonnet is needed to protect the scalp and minimize heat loss if the weather is cool or to protect against sunburn -Overdressing in warm temperatures can cause discomfort, as can underdressing in cold weather -eyes should be shaded if it is sunny and hot Car seat safety -Infants should travel only in federally approved rear-facing safety seats secured in the rear seat using the vehicle safety belt -car safety seat that faces the rear gives the best protection for an infant's disproportionately weak neck and heavy head. In this position the force of a frontal crash is spread over the head, neck, and back; the back of the car safety seat supports the spine -Before discharge from the birth institution, infants born at less than 37 weeks of gestation should be observed in a car seat (preferably their own) for at least 90 to 120 minutes or a period of time equal to the length of the car ride home. This is known as the Infant Car Seat Challenge. Non-nutritive sucking -Sucking is the infant's chief pleasure -sucking needs may not be satisfied by breastfeeding or bottle-feeding alone -pacifier should be used when the infant is placed supine for sleep, and it should not be reinserted once the infant falls asleep -No infant should be forced to take a pacifier -Pacifiers are to be cleaned often and replaced regularly and should not be coated with any type of sweet solution -Pacifier use for breastfeeding infants should be delayed for 3 to 4 weeks to ensure that breastfeeding is well established. -Placing a pacifier in the infant's mouth as soon as the infant begins to cry can reinforce a pattern of distress and relief. Bathing -provides opportunities for: -cleansing the skin -observing the infant's condition -promoting comfort -parent-child-family interaction -important consideration in skin cleansing is the preservation of the skin's acid mantle, which is formed from the uppermost horny layer of the epidermis, sweat, superficial fat, metabolic products, and external substances such as amniotic fluid and microorganisms -best to use a cleanser with a neutral pH and preferably without preservatives or with preservatives recognized as safe and well tolerated in neonates -Sponge baths are usually given until the infant's umbilical cord falls off and the umbilicus is healed -daily bath is not necessary for achieving cleanliness and can do harm by disrupting the integrity of the newborn's skin -cleansing the perineum after a soiled diaper and daily cleansing of the face are usually sufficient -In general, infants should not be bathed more frequently than every other day; the hair should be shampooed once or twice a week -babies don't need to shower every single, day and at the beginning, you do not want to submerge them into the water, you want to use a sponge bath, but be really careful with the cord bc it can get a little wet, but not fully wet and you need to dry it really well bc they can get nasty and infected really easily, so we usually say don't put them down fully under water until the cord falls off. Cord Care -goal of cord care is to prevent or decrease the risk for hemorrhage and infection -cord stump is an excellent medium for bacterial growth and can easily become infected -recommendations for cord care include cleaning the cord with water (using cleanser sparingly if needed to remove debris) during the initial bath -stump and base of the cord should be assessed for edema, redness, and purulent drainage with each diaper change -area should be kept clean and dry and open to air or loosely covered with clothing. -If soiled, the area is cleansed with plain water and dried thoroughly -**diaper is folded down and away from the stump (and make sure you get the area really dry before putting new diaper on bc you do not want a warm and moist area) -cord begins to dry, shrivel, and blacken by the second or third day of life -stump deteriorates through the process of dry gangrene; therefore, odor alone is not a positive indicator of omphalitis (infection of the umbilical stump). -separation time is influenced by several factors, including type of cord care, type of birth, and other perinatal events -average cord separation time is 10 to 14 days, although it can take up to 3 weeks -Infant follow-up care -CPR -Practical suggestions for first week at home -Interpretation of crying and use of quieting techniques Crying: Crying is an infant's first social communication -cry to communicate that they are hungry, uncomfortable, wet, ill, or bored and sometimes for no apparent reason at all -Nurses should instruct new parents about strategies to calm a crying or fussy baby -Important characteristics of this sensory stimulation—whether tactile, vestibular, auditory, or visual—appear to be that the stimulation is mild, slow, rhythmic, and consistently and regularly presented. -1 week after date of birth or 72 hours after you are discharged home you need to see your pediatrician. -Recognizing signs of illness: Notify the pediatric health care provider if any of these signs occur: •Fever: temperature greater than 38° C (100.4° F) axillary •Hypothermia: temperature less than 36.5° C (97.7° F) axillary •Poor feeding or little interest in food: refusal to eat for two feedings in a row •Vomiting: more than one episode of forceful vomiting or frequent vomiting (over a 6-hour period) •Diarrhea: two consecutive green, watery stools •Decreased bowel movement: in a breastfed infant, fewer than three stools per day; in a formula-fed infant, less than one stool every other day •Decreased urination: fewer than six to eight wet diapers per day after 3 to 4 days of age •Breathing difficulties: labored breathing with flared nostrils or absence of breathing for more than 15 seconds •Cyanosis (bluish skin color) whether accompanying a feeding or not •Lethargy: sleepiness, difficulty waking, or periods of sleep longer than 6 hours (most newborns sleep for short periods, usually from 1 to 4 hours, and wake to be fed) •Inconsolable crying (attempts to quiet not effective) or continuous high-pitched cry •Bleeding or purulent (yellowish) drainage from umbilical cord or circumcision; foul odor or redness at the site •Drainage from the eyes

Care Management

Feeding readiness cues -Hand-to-mouth or hand-to-hand movements -Sucking motions -Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck -Mouthing -mother needs to understand infant behaviors in relation to breastfeeding and recognize signs that the baby is ready to feed -feeding-readiness cues or early signs of hunger -Instead of waiting to feed until the infant is crying in a distraught manner or withdrawing into sleep, the mother should attempt to breastfeed when the baby exhibits feeding cues. -those were all early signs of needing to feed and teach mom to catch those early signs (crying is a latte sign of hunger) Positioning -For the initial feedings it can be advantageous to encourage and assist the mother to breastfeed in a semi-reclining position with the newborn lying prone, skin-to-skin on the mother's bare chest -four traditional positions for breastfeeding are the football or clutch hold (under the arm), modified cradle, cross-cradle or across the lap, cradle, and side-lying -use the position that most easily facilitates latch while allowing maximal comfort -Mothers who gave birth by cesarean often prefer the football or clutch hold -modified cradle or across-the-lap hold works well for early feedings, especially with smaller babies -side-lying position allows the mother to rest while breastfeeding. Women with perineal pain and swelling often prefer this position -Cradling is the most common breastfeeding position for infants who have learned to latch easily and feed effectively -Mother should be as comfortable as possible. After arranging for privacy, the nurse might suggest that she empty her bladder and attend to other needs before starting a feeding session -holds the infant securely at the level of the breast, supported by firm pillows or folded blankets, facing toward her -baby's mouth is directly in front of the nipple -support the baby's neck and shoulders with her hand and not push on the occiput -body is held in alignment (ears, shoulders, and hips are in a straight line) during latch and feeding Latch -placement of the infant's mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal -In preparation for latch during early feedings the mother should manually express a few drops of colostrum or milk and spread it over the nipple -lubricates the nipple and entices the baby to open the mouth as the milk is tasted. -To facilitate latch the mother supports her breast in one hand with the thumb on top and four fingers underneath at the back edge of the areola -breast is compressed slightly with the fingers parallel to the infant's lips, as one might compress a large sandwich in preparing to take a bite, so an adequate amount of breast tissue is taken into the mouth with latch -If the infant is not readily opening the mouth, the mother tickles the baby's lips with her nipple, stimulating the mouth to open. When the mouth is open wide and the tongue is down, the mother quickly "hugs" the baby to the breast, bringing him or her onto the nipple -amount of areola in the baby's mouth with correct latch depends on the size of the baby's mouth and the size of the areola and nipple -If breastfeeding is painful, the baby likely has not taken enough of the breast into the mouth, and the tongue is pinching the nipple Signs that the feeding is going well: -mother reports a firm tugging sensation on her nipple but feels no pinching or pain -baby sucks with cheeks rounded, not dimpled -baby's jaw glides smoothly with sucking -swallowing is usually audible When the infant is latched on and sucking correctly, breastfeeding is not painful: -feels pinching or pain after the initial sucks or does not feel a strong tugging sensation on the nipple, the latch and positioning are evaluated -signs of adequate latch and sucking are not present, the baby should be taken off the breast, and latch attempted again Frequency of feedings •Newborns: 8-12 times or every 2-3 hours** -Frequency is influenced by a variety of factors, including the infant's age, weight, maturity level, stomach capacity and gastric emptying time, and the storage capacity of the breast -Others cluster-feed, breastfeeding every hour or so for three to five feedings and then sleeping for 3 to 4 hours between clusters -During the first 24 to 48 hours after birth most babies do not awaken this often to feed. Parents need to understand that they should awaken the baby to feed at least every 3 hours during the day and at least every 4 hours at night -Once the infant is feeding well and gaining weight adequately, going to demand feeding is appropriate, in which case the infant determines the frequency of feedings -Should be fed whenever they exhibit feeding cues Duration of feedings •Average time = 15-20 minutes per breast** -As infants grow they become more efficient at breastfeeding, and consequently the length of feedings decreases -Nurses should teach them to look for signs that the baby has finished feeding (e.g., the baby's sucking and swallowing pattern has slowed, the breast is softened, the baby appears content and may fall asleep or release the nipple). -If a baby seems to be feeding effectively and urine output and bowel movements are adequate but the weight gain is not satisfactory, the mother may be switching to the second breast too soon -Feeding on the first breast until it softens ensures that the baby receives the higher-fat hindmilk, which usually results in increased weight gain Effective feeding -feeding diary can be helpful -recording the time and length of feedings and infant urine output and bowel movements -take this feeding diary to the follow-up visit with the infant's health care provider -output is highly indicative of feeding adequacy -As the volume of breast milk increases, urine becomes more dilute and should be light yellow; dark, concentrated urine can be associated with inadequate intake and possible dehydration -At least six to eight sufficiently wet diapers (light yellow urine) every 24 hours after day 4 -If the mother's milk has come in by day 3 or 4, the stools start to appear greenish yellow and are looser -By the end of the first week breast milk stools are yellow, soft, and seedy (they resemble a mixture of mustard and cottage cheese -If an infant is still passing meconium stool by day 3 or 4, breastfeeding effectiveness and milk transfer should be assessed. -Infants should have at least three stools (quarter-size or larger) per day for the first month Supporting breastfeeding mothers and infants Providing education and support -Key to encouraging mothers to breastfeed is education and anticipatory guidance, beginning as early as possible during and even before pregnancy -Prenatal education and preparation for breastfeeding influence feeding decisions, breastfeeding success, and the amount of time that women breastfeed -Prenatal preparation ideally includes the father of the baby, partner, or another significant support person and provides information about benefits of breastfeeding and how he or she can participate in infant care and nurturing -Support groups such as La Leche League provide information about breastfeeding along with opportunities for breastfeeding mothers to interact with one another and share concerns -Community-based peer counseling programs such as those instituted by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are beneficial -First 2 weeks of breastfeeding can be the most challenging as mothers are adjusting to life with a newborn, the baby is learning to latch on and feed effectively, and the mother may be experiencing nipple or breast discomfort -Primiparous women are most likely to experience early breastfeeding problems, which often result in less exclusive breastfeeding and shorter duration of breastfeeding. Common reasons for cessation -milk supply, painful nipples, and problems getting the infant to feed -Early and ongoing assistance and support from health care professionals to prevent and address problems with breastfeeding can help promote a successful and satisfying breastfeeding experience for mothers and infants -can only hold about 30mL, by the end of the first week, can hold 60-90 mL ? - recording -pic shows what tells you breastfeeding is going really well. Moms will get very thirsty when breastfeeding -wet diapers is very good indication of feeding**

Physiologic Problems

Jaundice Assessment: -Every newborn should be assessed for jaundice at least every 8 to 12 hours -differentiate cutaneous jaundice from normal skin color, the nurse applies pressure with a finger over a bony area (e.g., the nose, forehead, sternum) for several seconds to empty all the capillaries in that spot, then releases the pressure by lifting the finger. If jaundice is present, the blanched area will appear yellowish before the capillaries refill. -conjunctival sacs and buccal mucosa also are assessed, especially in darker-skinned infants -Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls can distort the actual skin color -If an infant appears jaundiced in the first 24 hours of life, a TcB or total serum bilirubin (TSB) level should be measured and results interpreted based on the newborn's age in hours -Repeat testing is based on the risk level (low, intermediate, or high), the age of the neonate, and the progression of jaundice Screening: -AAP recommend routine screening of all newborns before hospital discharge using TcB or serum bilirubin measurement Adequate feeding is essential in preventing hyperbilirubinemia: -Newborns should breastfeed early (within 1 to 2 hours after birth) and often (at least 8 to 12 times/24 hours or every 2-3 hours) -Colostrum acts as a laxative to promote stooling, which helps rid the body of bilirubin -Formula-fed infants should be fed after birth when their physiologic status has stabilized and thereafter at least every 3 to 4 hours. Assessment of risk factors for severe hyperbilirubinemia is advised: -most common risk factors include -gestational age less than 38 weeks -exclusive breastfeeding -significant jaundice in a sibling -isoimmune or other hemolytic disease -Cephalhematoma -significant bruising -East Indian race -decision to treat an infant for hyperbilirubinemia is based on total serum bilirubin levels, the infant's gestational age, and the 32 presence of risk factors -goal of treatment of hyperbilirubinemia is to help reduce the newborn's serum levels of unconjugated bilirubin Phototherapy -reduce the level of circulating unconjugated bilirubin or keep it from increasing -uses light energy to change the shape and structure of unconjugated bilirubin, converting it into a conjugated form that can be excreted through urine and stool -delivered through lamp, blanket, pad, or cover-body devices -severity of the newborn's hyperbilirubinemia determines the type of phototherapy device and strength of light, duration of treatment, and venue -neonate's response to phototherapy depends on the bilirubin level, the effectiveness of the phototherapy device, and the infant's ability to excrete the bilirubin -converts to water soluble Exchange -When phototherapy is not effective in reducing serum bilirubin levels or with severe hyperbilirubinemia such as in hemolytic disease, exchange transfusion may be needed -Infant's blood is replaced with a combination of blood products such as red blood cells (RBCs) mixed with 5% albumin or fresh frozen plasma -will not be asked on exchange therapy**

The newborn HR is 120, has a weak cry, muscle tone is flaccid, grimaces with bulb suction, and body is pink with blue extremities. APGAR?

Answer: 5 (0-10)

Hepatic

Carbohydrate metabolism -Liver regulates glucose by converting excessive glucose to glycogen and converting glycogen to glucose when glucose levels are low -At birth the newborn is cut off from its maternal glucose supply and as a result experiences an initial decrease in serum glucose levels -Glucose levels reach a low point between 30 and 90 minutes after birth and then rise gradually -healthy term newborns blood glucose levels stabilize at 40 to 60 mg/dl during the first several hours after birth -initiation of feedings helps to stabilize the newborn's blood glucose levels -blood glucose levels less than 40 mg/dl are considered abnormal and warrant intervention -classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures; or the infant can be asymptomatic -Hypoglycemia in the initial newborn period is most often transient and easily corrected through feeding -if baby has no temp issues, you should feed the baby for the first time within the first 60 min after birth- at least by that time so that we avoid hypoglycemic event. Coagulation -Coagulation factors, which are synthesized in the liver, are activated by vitamin K -lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life -Levels of coagulation factors slowly increase to reach adult levels by the age of 9 months Bilirubin *3rd most critical after the respirations and temp. -RBC's have shorter life span in neonate and increased count at birth results in higher level of bilirubin production -Heme broken down into reticuloendothelioal cells, converted to bilirubin and released in unconjugated form (indirect) -Plasma protein is really albumin -Bilirubin that is not bound to albumin, or free bilirubin, can easily cross the blood-brain barrier and cause neurotoxicity (acute bilirubin encephalopathy or kernicterus) -effectiveness of bilirubin excretion through the feces depends on the stooling pattern of the newborn and the substances in the intestine that break down conjugated bilirubin -feeding is important in reducing serum bilirubin levels -Feeding also introduces bacteria to aid in the reduction of bilirubin to urobilinogen -When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma levels of bilirubin increase, and jaundice appears -in order for bilirubin to conjugate, you have to get married and it has to marry a plasma protein, which in most cases, is albumin. Once it is conjugated, then it is excreted in urine or feces. If it does not marry, it stays unconjugated. -feeding is really important with this bilirubin process bc (at the end of the chart, the last thing is excretion), and if baby is feeding, it helps digestion and peristalsis to get everything moving and then excrete everything out. -If baby is not getting enough fluids to get things moving, or baby is not feeding enough or as often, or lots of vomiting and don't have enough going through their system. You have to get everything in the excreting process to get it all out and that is how feeding is related to bilirubin. -Phototherapy actually helps this conjugation to help baby excrete and turns it into this water soluble state to come out. Risk: -higher RBC mass at birth and shorter life span of neonatal RBCs mean that there is a need for greater bilirubin synthesis 12 -ability of the liver to conjugate bilirubin is reduced during the first few days after birth; it can metabolize and excrete only about two thirds of the circulating bilirubin -there are fewer bilirubin binding sites because newborns have lower serum albumin levels

A client is concerned because her 1 day old son, who was very alert at birth and is now sleeping most of the time. The best nursing response would be:

"Most infants are alert at birth and then require deep sleep to recover from the birth experience"

The pediatric nurse is being pulled to the nursery for the day. Which 3 neonates are the best client care assignment for the pediatric nurse? Select All that apply (if someone is being pulled to a different unit, they don't know everything so you need to give them the least invasive patients possible) 1. A 4 hour old with a blueish appearance to the hands and feet 2. A recent admission with APGAR score of 8 and 10 3. A 2-day old who has not passed a meconium stool (need to pass it within the first 2-8 hours after birth, so this is abnormal) 4. A 1-day old with a cleft palate and cleft lip (peds nurse may not know how to feed the baby, etc.) 5. An 18-hour postterm breastfed neonate with jaundice (pathologic appears before 24 hours old- pathologic is a little worse than physiologic; physiologic doesn't appear until after 24 hours, more like day 2,3,4 but both are abnormal) 6. A 1-day old with caput succeduem

1, 2, 6 (these are the least severe patients)

G8 P4 client just delivered baby Charlie at 0623. What is the nurse's initial action? 1. Clamp and cut the cord 2. Apply erythromycin ointment to both eyes 3. Dry and place a cap on his head 4. Obtain hand and foot prints

3; -clamping the cord is the providers job unless the nurse delivers, but the priority is to dry and put cap on the baby.

The nurse has received a shift report on a group of newborns. The nurse should make rounds on which client first? 1. "Newborn who is LGA and needs a repeat blood glucose prior to their next feeding in 15 min" 2. "Neonate born at 36 weeks gestation weighing 5 lb and due to breastfeed for the first time in 15 minutes 3. "Neonate born 24 hours ago by C/S and had a respiratory rate of 64 approximately 30 minutes ago" (normal is 30-60) 4. "Newborn who had a temp of 97.6 and was double wrapped with a hat on 30 minutes ago to bring up the temperature"

3; think ABC's to make sure the baby does not have other signs of respiratory distress.

A 1-week postpartum mother calls the unit to inquire about a tender, hard area on her left breast. What is the nurse's initial response. 1. "This is a normal response at 1-week." 2. "Notify the HCP" 3. "Stop breastfeeding because you probably have an infection" 4. "Massaging the area and applying heat packs before and cold packs after"

4

When developing a nursing care plan for an infant receiving phototherapy, the nurse should include what information? SATA 1 Adequate skin exposure to phototherapy 2. Allowing mother to hold infant as much as she wants 3. Eye protection 4. Supplemental water between feedings 5. Thermoregulation 6. Supplement formula for breastmilk

Answer: 1, 3, and 5 1 although we want mom to bond, we need baby under the lights 4 we do not need to supplement with water, but we can hydrate with formula and breastmilk (dehydration is correlated with phototherapy so we just want to make sure baby is having appropriate output and be watching for that sign of dehydration) 6 mom can still breastfeed and put baby back under light or warmer

1. Increase the IV rate 2. Provide supplemental oxygen 3. Record the finding on the EHR and repeat the reading in 30 min 4. Wrap the neonate to increase body temp

Answer: 2 -babies skin should not be pale, the O2 sat is abnormal at 4 hours. -blood glucose, temp, and respirations go together. 1 we don't know if baby has IV 4 we don't know what the babies temp was 3 we will need to intervene now and not just wait

After receiving change of shift report in the normal newborn nursery, the nurse should see which neonate first? 1. 3 hour-old with increased respiratory secretions 2. 5-hour old with blood glucose of 25 3. 12-hour old with temp of 97.4 4. 24-hour old with no urine output for the past 12 hours

Answer: 2 (normal blood glucose is 40-60 and the glucose is most unstable. 25 is really low and the baby needs to eat now) 1- this is pretty normal after birth and we suction to help with secretions 3 -97.6 and below is abnormal and we are concerned but glucose is most concerning 4- we are concerned with this baby, but we don't know how many wet diapers they had before

Which infant is at greatest risk to develop cold stress? 1. Full term infant delivered vaginally without complications 2. 36-week infant with an APGAR score of 7 at 5 min 3. 38-week female infant delivered via C/S bc of cephalopelvic disproportion 4. Term infant delivered vaginally with epidural anesthesia

Answer: 2; preterm with Apgar score of 7 (8-10 is out best). Your preterm infants have the most difficulty transitioning and have to figure out their thermoregulation. 4- that does not relate to the question 3- CPD does not necessarily mean the baby is in distress -Route of delivery does not play a factor in temp stability. -Cold stress is been passed of the baby's temp going down, using reserves of brown fat to keep it warm, sugar can go down faster, could have respiratory issues, etc.

Based on periods of reactivity, what should the nurse encourage the mother of a term neonate to do approximately 90 minutes after birth? 1. Feed the neonate 2. All the neonate to sleep 3. Get to know the neonate 4. Change the neonate's diaper

Answer: 2; the neonate is in the period of decreased responsiveness at 90 min, so you should allow the baby to sleep. 1- feeding the neonate should occur within the first hour

1. The newborn needs to be reweighed 2. Supplementation is now needed 3. Breastfeeding is going as expected 4. The HCP needs to be notified

Answer: 3 -The have lost about 7% and that is a normal amount of weight loss.

A new client asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is: 1. "It was ordered by your physician." 2. "This is done to accurately determine the gestational age of your newborn." 3. "It helps us identify infants who are at risk for any problems." 4. "The gestational age determines how long the infant will be hospitalized."

Answer: 3 2- i will not accurately tell us, but will get us close.

Despite placing a newborn skin-to-skin on the mother at delivery, the infant's temp is 96.4 F. Which initial actions should be implemented? (SATA) 1. Placing a knit hat on the baby 2. Drying the baby well 3. Place the baby in an incubator 4. Use an overbed warmer 5. Wrap the infant in warmed blankets 6. Provide warmed intravenous fluids

Answers: 1,2,5 1- make sure they do this bc lose heat through head 2- make sure baby is dried extremely well bc any fluid on baby can lead to coldness 5- you would do this 3- incubator means baby is completely closed in 4-you would prefer to keep baby with mom so would not use the overbed warmer 6- we are not giving IV fluids

Formula Feeding

Parent education -Majority of infants receive some amount of formula -Primary food or combine with BF Readiness for feeding -Cues include stability of vital signs, effective breathing pattern, presence of bowel sounds, active sucking reflex Feeding patterns -First 24-48 hours: 15-30 ml per feeding -Gradual increase during first week -90-150ml per feeding by end of second week -Feed every 3-4 hours -Rigid schedule not recommended -When showing adequate weight gain, allow to sleep and only feed on awakening -Usually predictable pattern by 3-4 weeks -Increase in appetite at 10 days, 3 weeks, 6 weeks, 3 months, and 6 months -Increase by approx 30 ml to meet needs Feeding technique -Should be held for all feedings; never prop bottle and look away (make sure mom knows to always hold the bottle so it is properly positioned for the baby) -semi-upright position with good head support ** (never have them laying down while feeding) -Peaceful and relaxed -Encourage skin to skin -Slow-flow nipple in beginning to allow for coordination of sucking, swallowing and breathing -If fall asleep, usually means eaten enough, don't overfeed -Observe for signs of choking -Turning head, arching back, choking, sputtering, changing color, moving arms, tensing fists -Stop feeding and calm infant -Must burp after due to swallowing of air*** - burping is important Common concerns Spit up (if it very common!!!) -Decrease amount of feeding or smaller amounts more frequently -Burp during feedings -Hold upright for 30 min after -Report vomiting 1/3 or more of feeding or projectile vomiting Bottles and nipples -Various brands -Wash in warm soapy water using bottle/nipple brush -Boil in water for 5 min and air dry for first use and every so often unless in dishwasher -they need to be properly cleaned in between feedings to prevent infection. You need to sanitize a least every week; and use soap and water between each use. -Idea is to resemble human milk -Composition varies with manufacturer but must meet specific standards -Commercial iron-fortified Cow's milk-based formulas: Removed butterfat, decreased protein and add vegetable oil and carb; Variations occur with source of carb, nucleotides to enhance immune function, and DHA, ARA (improve visual and cognitive function)- this is the typical formula If babies have special needs with formula, here are some options: Soy-based formulas: lactose or cow's milk protein intolerant -Galactosemia -Congenital lactase deficiency Casein- or whey-hydrolysate formulas: cannot tolerate or digest cow's milk or soy-based Amino acid formulas: multiple food protein intolerances •Formula preparation •Powdered formula: Least expensive, mix one scoop per 60ml •Concentrated formula: Diluted with equal parts water and stored in fridge for 48 hours after opening •Ready-to-feed: -Most expensive and easiest -Pour into bottle -Good for 48 hours* (once you start a bottle, it needs to be finished within 48 hours) -Can be bought in disposable bottles -never heat up breast milk or formula in a microwave! -Must have access to safe, public water -Sterile water or boil water •Vitamin and mineral supplementation -After 6 mo need fluoride supplementation based on levels in water

Care Management cont.

Supplements -Unless a medical indication exists, no supplements should be given to breastfeeding infants -Early supplementation by hospital staff undermines a new mother's confidence and models behavior that is counterproductive to establishing breastfeeding -When supplementation is deemed necessary, giving the baby expressed breast milk is best -Before supplementation it is important to perform a careful evaluation of the mother-infant dyad -Possible indications for supplementary feeding include infant factors such as hypoglycemia, dehydration, weight loss of more than 7% associated with delayed lactogenesis, delayed passage of bowel movements or meconium stool continued to day 5, poor milk transfer, or hyperbilirubinemia -Maternal indications for possible supplementation include delayed lactogenesis and intolerable pain during feedings. Women who have had previous breast surgery such as augmentation or reduction may need to provide supplementary feedings for their infants Bottles Newborns can become confused going from breast to bottle or bottle to breast when breastfeeding is first being established -Breastfeeding and bottle feeding require different oral motor skills -Best to avoid bottles until breastfeeding is well established, usually after 3 or 4 weeks If supplemental feeding is needed, nurses or lactation consultants can help parents use supplemental nursing devices -allows the baby to be supplemented with expressed breast milk or infant formula while still breastfeeding -can also be fed with a spoon, dropper, cup, or syringe. If parents choose to use bottles, a slow-flow nipple is recommended Pacifiers -Because of the correlation between pacifier use and a decreased risk of sudden infant death syndrome (SIDS), experts recommend pacifier use for healthy term infants at nap or sleep time, but only after breastfeeding is well established at about 3 or 4 weeks of age. -if mom is breastfeeding, there is something called nipple confusion so best to wait 3-4 weeks before introducing it. Special considerations Sleepy baby -Some babies need to be awakened for feedings for the first few days after birth -If the infant is awakened from a sound sleep, attempts at feeding may be unsuccessful -More likely to feed if they are awakened from a light or active sleep state -Signs that the infant is in this sleep state are movements of the eyelids, body movements, and making sounds while sleeping -Unwrapping the baby, changing the diaper, sitting the baby upright, talking to him or her with variable pitch, gently massaging his or her chest or back, and stroking the palms or soles may bring the baby to an alert state -Helpful to place the sleepy baby skin-to-skin with the mother; she can move the infant to the breast when feeding-readiness cues are apparent -you do not want babies to be fussy before feeding, and you need to calm them down, you want them to be in a restful state before feeeding. Fussy baby -sometimes awaken from sleep crying frantically -cannot focus on feeding until they are calmed -swaddle the baby, hold him or her close, talk soothingly, and allow him or her to suck on a clean finger until calm enough to latch on to the breast -Placing the baby skin-to-skin with the mother can be very effective in calming a fussy infant -Fussiness during feeding can be the result of birth injury such as bruising of the head or fractured clavicle -Changing the feeding position can help alleviate this problem -Can become fussy and appear discontented when sucking if the nipple does not extend far enough into the mouth -Feeding can begin with well-organized sucks and swallows, but the infant soon begins to pull off the breast and cry -Mother should support her breast throughout the feeding so the nipple stays in the same position as the feeding proceeds and the breast softens -Can be related to GI distress (e.g., cramping, gas pains, gastroesophageal reflux -in response to an occasional feeding of infant formula, or it can be related to something the mother has ingested, although most women are able to eat a normal diet without causing GI distress to the breastfeeding infant -persistent crying or refusing to breastfeed can indicate illness Slow weight gain -typically lose 5% to 6% of body weight after birth before they begin to gain weight -Weight loss of more than 7% in a breastfeeding infant during the first 3 days of life needs to be investigated -the early milk has transitioned to mature milk, infants should gain approximately 110 to 200 g (3.9 to 7 oz) per week or 20 to 28 g (0.7 to 1 oz) per day for the first 3 months Breastfed infants usually do not gain weight as quickly as formula-fed infants -Warning signs of ineffective breastfeeding, including: inadequate weight gain, minimal output, and feeding constantly -related to inadequate breastfeeding: -short or infrequent, or the infant can be latching incorrectly or sucking ineffectively or inefficiently -Other possibilities are illness or infection; malabsorption; or circumstances that increase the baby's energy needs such as congenital heart disease, cystic fibrosis, or simply being small for gestational age -Slow weight gain must be differentiated from failure to thrive Maternal factors can be the cause of slow weight gain: -Problem with inadequate emptying of the breasts, pain with feeding, or inappropriate timing of feedings -Inadequate glandular breast tissue or previous breast surgery can affect milk supply -Severe intrapartum or postpartum hemorrhage (Sheehan syndrome), illness, or medications can decrease milk supply -Stress and fatigue also negatively affect milk production In most instances the solution to slow weight gain is to increase feeding frequency and to improve the feeding technique: -Positioning and latch are evaluated, and adjustments are made -Adding a feeding or two in a 24-hour period can help -If the problem is a sleepy baby, parents are instructed in waking techniques -Using alternate breast massage during feedings can help increase the amount of milk going to the infant Preterm and late preterm infants -Human milk is the ideal food for preterm infants, with benefits that are unique and in addition to those received by term healthy infants -enhances retinal maturation in the preterm infant and improves neurocognitive outcomes; it also decreases the risk of sepsis and necrotizing enterocolitis -greater physiologic stability occurs with breastfeeding compared to bottle feeding Initially preterm milk contains higher concentrations of energy, protein, sodium, chloride, potassium, iron, and magnesium than term milk -more similar to term milk by approximately 4 to 6 weeks -Depending on gestational age and physical condition, many preterm infants are capable of breastfeeding for at least some feedings each day -not able to breastfeed their infants should begin pumping their breasts as soon as possible after birth -Pumping frequency depends on the mother's breastfeeding goals but may be recommended 8 to 10 times every 24 hours to establish the milk supply -Kangaroo care (skin-to-skin contact) is encouraged until the baby is able to breastfeed and while breastfeeding is established because it enhances milk production Receive specific emotional benefits in breastfeeding or providing breast milk for their babies -find rewards in knowing that they can provide the healthiest nutrition for the infant and believe that breastfeeding enhances feelings of closeness to the infant Late preterm are at risk for feeding difficulties because of their low energy stores and high energy demands -more prone to hypothermia, hypoglycemia, and hyperbilirubinemia -tend to be sleepy, with minimal and short wakeful periods -often tire easily while feeding and have a weak suck and low tone; these factors can contribute to inadequate milk intake resulting in dehydration and poor weight gain -predisposes mothers to delayed onset of lactogenesis II and inadequate milk supply -Early and extended skin-to-skin contact promotes breastfeeding and helps prevent hypothermia -more prone to positional apnea than term infants, mothers are advised to use the clutch (under the arm or football) or cross-cradle hold for feeding, and avoid flexing the head, which can impede breathing Breastfeeding multiple infants -especially beneficial to twins, triplets, and other higher-order multiples because of the immunologic and nutritional advantages and the opportunity for the mother to interact with each baby frequently -*Most mothers are capable of producing an adequate milk supply for multiple infants -mothers and their husbands or partners need extra support and help to learn how to manage feedings Maternal employment -Returning to work after birth is associated with a decrease in the duration of breastfeeding -face workplace challenges in breastfeeding such as lack of flexibility in work schedules, inadequate breaks to allow time for pumping, lack of privacy, lack of space for pumping, and lack of support from supervisors or coworkers -Issues that can affect continued breastfeeding while working include fatigue, child care concerns, competing demands, and household responsibilities -Set realistic goals for employment and breastfeeding, with accurate information regarding the costs, risks, and benefits of available feeding options -Settings mothers are able to breastfeed during the workday, either by going to an on-site daycare center or by having a friend or relative bring the baby to her for some feedings -Pump their milk while they are at work and save the milk for later feedings -Affordable Care Act (USDHHS, 2010a) mandates that employers provide accommodations for breastfeeding mothers, specifically reasonable breaks during the workday and a non-bathroom space for milk expression until the child's first birthday Weaning -initiated when babies are introduced to foods other than breast milk and concludes with the last breastfeeding -Gradual weaning over weeks or months is easier for mothers and infants than abrupt weaning -Abrupt weaning is likely to be distressing for mother and baby and physically uncomfortable for the mother because it can cause engorgement and mastitis -you can start introducing foods at around 6 months, such as iron fortified cereals. It is a slow introduction, and you would still be feeding both. Initiated by either the infant or the mother: -infant-led weaning the infant moves at his or her own pace in omitting feedings, which usually facilitates a gradual decrease in the mother's milk supply -mother-led weaning means that the mother decides which feedings to drop -most easily undertaken by omitting the feeding of least interest to the baby or the one through which the infant is most likely to sleep -every few days thereafter the mother drops another feeding until the infant is gradually weaned from the breast -can be weaned directly from the breast to a cup -Bottles are usually offered to infants younger than 6 months -weaned before 1 year of age, the infant should receive iron-fortified formula instead of cow's milk -To relieve the discomfort of engorgement the mother can take mild analgesics such as ibuprofen, wear a supportive bra, apply ice packs or cabbage leaves to the breasts, and pump small amounts if needed -very emotional time for mothers; many believe that it is the end to a special, satisfying relationship with the infant and benefit from time to adapt to the changes -Sudden weaning can evoke feelings of guilt and disappointment. -women go through a grieving period after weaning

Things for test:

it is 40 questions - evenly split 20/20 for postpartum and newborn

Postpartum Psychosis

•Most severe of perinatal mood disorders •Affects 0.1%-0.2% of postpartum women (really rare but the worst) •Symptoms: they develop auditory and visual hallucinations, or delusions and look a lot like schizophrenia (such as thinking her baby is demon possessed, or her baby has some kind of special powers, or be accusatory that she thinks families or nurses are trying to harm her baby. She also may be paranoid and insist that something is wrong with her baby when baby doesn't. She can also have impulsivity and have suicidal and homicidal thoughts which is concerning bc she may go through with it.She has very clouded judgement and don't have the ability to make decisions.) -This is a true psychiatric emergency and she needs to be admitted to a psych unit be •Medical management: mood stabilizers will be used, and antipsychotic drug, or electroconvulsive therapy in conjunction with meds are seen to be helpful. -once the worst, acute phase has past, therapy is also good for them. With treatment, it is something that will improve over several months. -when we have a psychotic PP mom, we definitely want to separate mom and baby initially, and slowly reintroduce baby back to mom and all babies need to be supervised. Postpartum Psychological Complications •Referrals: we want to make referrals to the appropriate providers (so if she went to the OB provider, they don't need to take care of it and need to go to a mental health doctor) •Psychiatric hospitalization and safety (esp. when most has a lack of judgement and has those suicidal and homicidal thoughts with impulsity) •Antidepressants/psychotropic medications and lactation (all meds get into the milk to some degree, but whether the class of drugs, there is always some drugs that are better than others in that class for breastfeeding) -Important to always weight risks vs. benefits ( If there is a med that mom may really need to take but not really safe for breast-feeding, may need to stop breastfeeding, or find a safer option) -LactMed- complete drugs and lactation database available online (helps with choosing the correct meds for a mom) Care Management: Early identification is key -PP nurses can screen for PPD prior to discharge- usually you will be screening more for risk factors of it bc you normally would not see it within 2-3 days of being in the hospital -Follow-up screening of the mother by pediatrician at infant's visits and at mother's PP follow-up (bc these people will see it in the follow up visits) -Educate family members (bc they are the ones who spend the most time with her and will be able to identify when something is of with mom) -p. 671 "Teaching for Self-Management" •Most common time for symptoms of PPD to manifest is around 4 weeks postpartum (but that does not mean it is the only time it can manifest, it may come on several months after delivery)

Neonatal Pain

•Neonatal responses to pain -response is influenced by a variety of factors such as characteristics of the painful stimulus, gestational age, biologic factors, and behavioral state -source, location, and timing of the pain affect the response; newborns respond differently to acute pain than to prolonged or recurrent pain -Pain perception and stress can be greater in preterm infants, although they often display less vigorous pain responses than term infants -differences in pain responses related to the amounts and types of neurotransmitters and receptors available to mediate pain -behavioral state of the neonate also affects the pain response -Those who are more awake tend to have more robust pain responses than those in sleep states -common behavioral sign of pain is a vocalization or crying, ranging from a whimper to a distinctive high-pitched, shrill cry -Facial expressions include grimacing, eye squeeze, brow contraction, and an open mouth -infant will flex and adduct the upper body and lower limbs in an attempt to withdraw from the painful stimulus -can result in significant changes in heart rate, blood pressure (increased or decreased), intracranial pressure, vagal tone, respiratory rate, and oxygen saturation •Assessment of pain -In assessing pain the nurse needs to consider the health of the neonate, the type and duration of the painful stimulus, environmental factors, and the infant's state of alertness -CRIES is an acronym for the physiologic and behavioral indicators of pain used in the tool: crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness -tool was developed for use by nurses who work with preterm and term infants -Used by nurses in some neonatal intensive care units (NICUs) •Neonatal Infant Pain Scale •Premature Infant Pain Profile •Neonatal Pain Agitation and Sedation Scale •CRIES Management of neonatal pain -goals of the management of neonatal pain are to (1) minimize the intensity, duration, and physiologic cost of the pain and (2) maximize the neonate's ability to cope with and recover from the pain. Nonpharmacologic management: Containment (swaddling): -limits the neonate's boundaries, aids in self-regulation, and reduces physiologic and behavioral stress resulting from acute pain -Safe swaddling involves wrapping the infant snugly in a blanket with the arms extended legs flexed, and hips in neutral position without rotation -Facilitated tucking, a hand-swaddling technique in which the care provider holds the neonate in a flexed, side-lying position, is effective for reducing pain and distress in preterm infants Nonnutritive sucking and Oral glucose -Nonnutritive sucking (NNS) on a pacifier is a common comfort measure used with newborns -Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking is safe and effective in reducing neonatal pain during painful procedures such as venipunctures or heelsticks -Oral sucrose and NNS used in combination before or during a painful procedure can help reduce discomfort Skin-to-skin contact and breastfeeding -Skin-to-skin contact with the mother who holds the infant prone on her chest, also known as kangaroo care, during a painful procedure can help reduce pain -Breastfeeding or breast milk helps reduce pain during heel lancing and blood collection -Also good for bonding, regulates the temp, HR, RR, etc. for baby Distraction -visual, oral, auditory, or tactile stimulation can be helpful in term neonates or older infants -Sensorial saturation uses multiple senses to diminish minor pain. This technique involves speaking softly to the infant, massaging the face, and providing oral sucrose solution on the tongue. -Other nonpharmacologic measures for reducing pain in newborns include touch, massage, rocking, holding, and environmental modification -Combining two or more nonpharmacologic methods can result in more effective pain reduction. Pharmacologic management: -Local anesthesia is routinely used during procedures such as circumcision and chest tube insertion -Topical anesthesia is used for circumcision, lumbar puncture, venipuncture, and heelsticks -Nonopioid analgesia (oral liquid acetaminophen) is effective for mild to moderate pain from inflammatory conditions -Morphine and fentanyl are the most widely used opioid analgesics for pharmacologic management of neonatal pain -Continuous or bolus IV infusion of opioids provides effective and safe pain control.

Care of the Mother

Nutrition -450-500 calories per day -Weight loss 2-4 pounds per month (but don't want mom to lose weight too fats so make sure it is a slow weight loss) -Multivitamin/DHA 200-300 mg (should be encouraged to still take prenatal vitamins) -Caloric intake during lactation should be sufficient to achieve the goal of balancing energy intake and expenditure -women who are breastfeeding tend to lose weight more quickly than those who are formula feeding -Medications or diets that promote weight loss are not recommended for breastfeeding mothers -Rapid loss of large amounts of weight can be detrimental, given that fat-soluble contaminants to which the mother has been exposed are stored in body fat reserves and these can be released into the breast milk -potential consequence of weight loss is reduced milk production -encouraged to drink fluids in response to thirst (women often report feeling thirsty when they are breastfeeding) Rest -As much as possible especially in first 1-2 weeks -Fatigue, stress and worry negatively affect production and let-down -Sleep when baby sleeps -Others can help with household chores and caring for other children Breast care -Soap has drying effect on nipples -Flat/inverted nipples -Breast shells in bra: exert mild pressure around base of nipple to encourage nipple version -Wear a bra because ligaments will stretch and be painful -Underwires/improper fit can cause clogged milk ducts -Wear breast pads if leaking, change when damp Breastfeeding during pregnancy -Continue if no medical complications -Nipple tenderness (with preg) can cause discomfort when BF -Taste and composition are altered Tandem nursing -BF a newborn and older child (can do both but make sure you feed the baby first) -Feed infant first!! -Similar supply meets demand as in feeding multiples Breastfeeding after breast surgery -Can affect ability to produce milk and/or transfer to infant -Damaged nerves and interrupt milk ducts -Augmentation: -Sometimes successful (more successful than a reduction) -If due to hypoplastic/assymetric breasts or breast reconstruction can have concerns -Submuscular: less likely to cause problems Periareolar incisions: can have problems -Large implants: can impede milk flow through compressed ducts If breast reduction: Interference with ducts, removal of glandular tissue, and nerve damage (may have more difficulty with breastfeeding) Cancer: Treatment can cause reduced supply or absence of lactation Breastfeeding and obesity -Delayed onset of lactogenesis stage II -Reduced production compared with average weight -Bariatric surgery: -When was surgery? -Stabilize 12-18mo after -1800 kcal/day, weight stabilized, milk may be adequate -May need dietary supplements Medications, alcohol, smoking, and caffeine Few drugs are contraindicated -Safety of med includes: -Pharmacokinetics of drug in maternal system Absorption/metabolism/distribution/storage/excretion in infant -GA and chronological age, body weight and BF pattern also considered -Benefits of BF versus risk of med to infant -May need to pump and dump if having tests with radioactive agents Adverse effects: -Antimetabolite and cytotoxic meds -Drugs of abuse (cocaine, heroin, amphetamines, phecyclidine) -Methadone: must be stable Postpartum pain: -Ibuprofen -Opiods: risk of sedation and sucking difficulties -Oxycodone less desirable due to high amounts transferred to infant leading to CNS depression -Lack of evidence on long-term effects of antidepressant, antianxiety and mood stabilizing meds -need to make sure that you are on medications that are safe for baby- risk versus benefits. If mom has to take meds and it is not safe for baby, then mom may just not be able to breastfeed. Alcohol -No standard rec on avoidance but should be aware of potential risks -Occassional consumption of 8 oz wine or 2 beers -Passes freely from blood to milk with peak levels in 30-60 min on empty stomach and 60-90 min with food -MER and milk production can be affected -If drinking, avoid BF for 2 hours after 1-2 drinks -can also pump and dump, but this does not accelerate removal of alcohol Smoking -Can impair production -Exposes infant to secondhand smoke -Nicotine transferred in breast milk with both smoking and patch -Do not smoke within 2 hours of breastfeeding and never with infant in same room. Caffeine -Moderate intake -Can accumulate in infants Herbals -Herbal teas can help increase milk supply -Lack of evidence of effectiveness and safety during BF -Unknown additives can be harmful to infant -Each herb should be evaluated for compatibility with BF Common concerns of the breastfeeding mother: Engorgement -Common in response to sudden change in hormones and onset of increased milk volume -3-5 days after when milk comes in Volume exceeds storage capacity of alveoli -If not removed, alveoli become distended -Capillary blood flow is impaired -Fluid leads into surround tissues causing edema -Ducts become compressed and milk cannot flow from breasts -Firm, tender, hot, shiny, taut -Areolae are firm, nipples flatten -If milk not removed, can diminish supply -Can resolve in 24 hours if feed or pump every 2 hours -Treatments: -Cold packs after BF for 15-20 min on breasts -Cabbage leaves: related to coolness and phytoestrogens, 15-20 min, frequent use can diminish supply -Warm packs before BF * bc it causes vasodilation and stimulates breast -Antiinflammatories: ibuprofen -Massage/pumping Sore nipples -Tenderness is common in first few days: -Should go away as milk comes in because it acts as lubricant -Use the colostrum as a chapstick for nipples -Severe soreness, painful, cracked, bleeding is not normal and usually due to poor positioning, improper latch, such, or infection -Treatment is focused on cause and correction of problem -Should heal within a few days -Assess for cracking which can increase risk of infection -Keep open to are as much as possible -Lanolin or hydrogel pads Insufficient milk supply -Evaluate for mother-infant dyad, infant weight gain, feeding technique, milk transfer, medical causes or stress/fatigue Interventions based on cause: -Skin to skin contact -increase feeding frequency -Pump to feed -Rest, healthy diet, reduce stress -Galactogogues: meds believed to increase supply -Fenugreek, blessed thistle, goat's rue, shatavari -Lack of evidence -Dopamine antagonists (Reglan) cause increase in prolactin levels which increases production Plugged milk ducts -Causes area to be swollen and tender -Does not empty with feeding/pumping Mastitis -Inflammation of breasts (this is the actual infection), flu-like symptoms (fever, chills, aches, HA) -Localized breast pain, tenderness, hot, red area -Common in upper outer quadrant, one or both -Usually during first 6 wks but really anytime -Treatment is analgesics, antibiotics, and antipyretics •Follow-up after discharge

Circumcision

-Removal of all or part of the foreskin of the penis -Usually it is performed during the first few days of life but is sometimes done at a later time for preterm or ill neonates or for religious or cultural reasons -health benefits include prevention of urinary tract infection in male infants younger than 1 year, reduced risk for penile cancer, and reduced risk for heterosexual acquisition of sexually transmitted infections, particularly HIV. -Policies and recommendations -Parental decision (it is their personal decision): so may do it later and others may not want to do it at all. It requires a separate consent -Procedure Prepare the infant for the circumcision -positioned on a plastic restraint form -penis is cleansed with soap and water or an antiseptic solution such as povidone-iodine -Draped to provide warmth and a sterile field, and the sterile equipment is readied for use Hospital setting newborn circumcision is usually performed using the Gomco (Yellen) or Mogen clamp or the PlastiBell device -based on health care provider training and preference -a few minutes to perform -Gomco or Mogen clamp involves surgical removal of the foreskin -clamp technique minimizes blood loss -small petrolatum gauze dressing is applied to the penis for the first 24 hours; thereafter, parents are instructed to apply petrolatum to keep the penis from adhering to the diaper -PlastiBell technique, the plastic bell is first fitted over the glans, a suture is tied around the rim of the bell, and excess foreskin is cut away -plastic rim remains in place for about a week; it falls off after healing has taken place, usually within 5 to 7 days -Petrolatum or dressings are not applied to the penis following circumcision with the PlastiBell -Pain management: -pain is characterized by both physiologic and behavioral changes in the infant -Four types of anesthesia and analgesia are used for newborn circumcision: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as eutectic mixture of local anesthetic (EMLA) (prilocaine-lidocaine) or LMX4 (4% lidocaine), and concentrated oral sucrose -Care of the circumcision: -infant can be fussy for several hours and can have disturbed sleep-wake states and disorganized feeding behaviors -site is assessed for bleeding every 15 to 30 minutes for the first hour and then hourly for the next 4 to 6 hours -the infant's urinary output, noting the time and amount of the first voiding after the circumcision -provide education for parents related to care of the circumcised infant, which includes observing for complications such as bleeding or infection -Newborns typically cry when the diaper is changed and when petrolatum gauze is removed and reapplied -can make new parents feel anxious because they do not want to inflict pain on the infant -inform parents that the discomfort is usually temporary and will soon subside

Uterus

-The biggest thing we want the uterus to do is contract and stay firm (not soft or boggy) to prevent bleeding and PP hemorrhage •Preventing excessive bleeding ▫Common cause: uterine atony (without tone- when the uterus is relaxed). Uterine atony is the most common cause of the excessive bleeding. ▫Prevention techniques: -Maintain uterine tone through fundal massage to keep it firm -Prevent bladder distention (bc a distended bladder keeps the uterus from contracting effectively) Lochia •Assess amount of the bleeding: -Scant, light, moderate, heavy, excessive (typically we will see light to moderate; we don't really ever want to see heavy or excessive) •Time of last pad change: we need to know this bc if there is a saturated pad and has been there for 6 hours versus only there for 1 hr, that is a big difference. If someone is saturating a pad in an hour, that is some heavy bleeding and we would be concerned about that and anything less than an hour is very concerning) •Color of lochia (is it dark red, bright red?- bright red bleeding could be a little concerning bc even the first day, the lochia should be a dark red.) •Clots (generally a few small clots are okay- like quarter size. but when we start passing bigger clots, we start getting worried about that and don't want to see big clots; it is common to see some clots come out if you are massaging the fundus) •Check beneath client (bc some of the bleeding can be under her bottom and on her back and there could be a lot more bleeding than we thought if you don't check under her) -Other ways to assess blood loss other than looking at it. You can look at H&H and weighing the pads to quantify it more. (1g=1mL generally). Other things we can tell is there has been an excessive amount of blood loss would be increased HR, decreased BP, changes in mental status such as confusion, lethargic, or dizzy where they stand up and almost pass out. Lochia Changes •Lochia Rubra—dark red -Days 1-3 •Lochia Serosa—brownish red/pink -Days 4-10 •Lochia Alba—yellow-white -After 10 days (can last several weeks) •Maintaining uterine tone ▫Fundal massage (this is the nurses intervention to prevent uterine atony to firm back up the uterus if it is boggy)- it requires 2 hands- one of the symphysis pubis and the other hand is to massage the fundus to anchor it and they are trying to prevent uterine inversion where the uterus can flip inside out from vigorous fundal massage. -Laying supine is ideal position to find the fundus. Location of fundus -this pic is showing the expected location of where to find the fundus. Don't get hung up on it being lower than it is expected to be bc we are wanting the fundus to go down and that is good. We are worried about where it is higher than it should be. We always want it to feel firm and feel it at the midline. -we are doing frequent checks of the fundus more frequently (x15 min in the 1st hour and x30 min in the 2nd hour). We do it bc the first hour and 2 are the prime time for a hemorrhage to occur (that is why they stay on the L&D floor for the first two hours and why we call it the 4th stage of labor) Measures that promote involution •Voiding (keeping the bladder as empty as possible) •Fundal massage (keeps the uterus contracting) •Breastfeeding (it increases the natural oxytocin release from the pituitary gland which causes cramping and helping contract) •Medications: -Oxytocin, Methergine, Hemabate (uterotonic meds that promote contractions) -we use the oxytocin as a preventative thing mainly. But if there is still excessive bleeding even with the the oxytocin going, then we will try methergine or hemabate •No results: notify health care provider (if we have tried all the things above)

Thermogenic cont.

-Vasoconstriction occurs, appears pale, mottled, skin feels cool Cold stress -If the hypothermia is not corrected it will progress to cold stress: imposes metabolic and physiologic demands on all infants, regardless of gestational age and condition -Respiratory rate increases in response to the increased need for oxygen: -oxygen consumption and metabolic rate (energy) are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival -If the infant cannot maintain an adequate oxygen tension, vasoconstriction follows and jeopardizes pulmonary perfusion -Surfactant synthesis altered resulting in respiratory distress -Cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids -Metabolic acidosis develops, and, if a defect in respiratory function is present, respiratory acidosis also develops -Excessive fatty acids can displace the bilirubin from the albumin-binding sites and exacerbate hyperbilirubinemia -Hypoglycemia is another metabolic consequence of cold stress, low glucose stores not replaced then hypoglycemia can develop Hyperthermia -body temperature greater than 99.5° F is considered to be abnormally high and is typically caused by excess heat production related to sepsis or a decrease in heat loss -can result from the inappropriate use of external heat sources such as radiant warmers, phototherapy, sunlight, increased environmental temperature, and the use of excessive clothing or blankets -clinical appearance of the infant who is hyperthermic often indicates the causative mechanism Infants who are overheated because of environmental factors such as being swaddled in too many blankets exhibit signs of heat-losing mechanisms: -skin vessels dilate -skin appears flushed -hands and feet are warm to touch -assumes a posture of extension Newborn who is hyperthermic because of sepsis appears stressed: -vessels in the skin are constricted -color is pale -hands and feet are cool -develops more rapidly in a newborn than in an adult because of the relatively larger surface area of an infant. Sweat glands do not function well. -When baby is cold and temp goes down, the O2 sat will drop, RR will go up, and when we increase our metabolic rate, we are using more glucose and so we would need to make sure they have plenty of formula or breastmilk. But, if baby is sick and can't feed, then we may need IV dextrose... Always think temp, RR (O2 demand), and glucose (metabolism) go together. Glucose goes don't bc you are using more of it for our body., RR go up bc trying to work harder to breathe and get the oxygen flowing through the body (HR could go up but don't worry about that) -Temp, respirations, and glucose** -Hyperthermia and temp bc of infection is different. Hyperthermia is just the baby is hot (higher than 99.5 is hyperthermia). With temp bc of infection, we still go by 100.4. -Anything less than 97.7 is hypothermia.*

Gastrointestinal

-full-term newborn is capable of swallowing, digesting, metabolizing and absorbing proteins and simple carbohydrates and emulsifying fats -The infant is unable to move food from the lips to the pharynx -Small whitish areas (Epstein pearls) may be found on the gum margins and at the juncture of the hard and soft palates -Peristaltic activity in the esophagus is uncoordinated in the first few days of life -It quickly becomes a coordinated pattern in healthy full-term infants, and they swallow easily -mucosal barrier in the intestines is not fully mature until 4 to 6 months of age, which allows antigens and other bacteria to be transported across the intestinal wall into the systemic circulation -increases the risk of allergies and infection -capacity of the newborn stomach varies widely, depending on the size of the infant, from less than 30 ml on day 1 to more than 90 ml on day 3 -After birth the newborn stomach becomes increasingly more compliant and relaxed to accommodate larger volumes -factors such as time and volume of feedings or type and temperature of food can affect the emptying time -newborns are prone to regurgitation, vomiting, and gastroesophageal reflux (GER). -Regurgitation is common among newborns and is most prevalent during the first 3 months -Vomiting and regurgitation can be decreased by avoiding overfeeding, burping the infant, and positioning him or her with the head slightly elevated •Digestion -infant's ability to digest carbohydrates, fats, and proteins is regulated by the presence of certain enzymes -All of these enzymes are functional at birth except for pancreatic amylase and lipase -newborn gets these through breastmilk. Stools (Box 23-1 Pg 468) -formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa). -greenish black and viscous and contains occult blood -meconium stool passed is usually sterile, but within hours all meconium passed contains bacteria -healthy term infants pass meconium within the first 12 to 24 hours of life, and almost all do so by 48 hours -Progressive changes in the stooling pattern indicate a properly functioning GI tract •Signs of risk for gastrointestinal problems GI Problems -time, color, and character of the infant's first stool should be noted -Failure to pass meconium can indicate bowel obstruction related to conditions such as an inborn error of metabolism (e.g., cystic fibrosis) or a congenital disorder -active rectal "wink" reflex (contraction of the anal sphincter muscle in response to touch) is a sign of good sphincter tone -Some infants are intolerant of certain commercial infant formulas -If an infant is allergic or unable to digest a formula, the stools can become very soft with a high water content that is signaled by a distinct water ring around the stool on the diaper -Forceful ejection of stool and a water ring around the stool are signs of diarrhea -Care must be taken to avoid misinterpreting transitional stools for diarrhea. The loss of fluid in diarrhea can rapidly lead to fluid and electrolyte imbalance Amount and frequency of regurgitation ("spitting up") or vomiting after feedings should be documented: -Color change, gagging, and projectile (very forceful) vomiting occur in association with esophageal and tracheoesophageal anomalies -Vomiting in large amounts, especially if it is projectile, can be a sign of pyloric stenosis -remember, the baby can't move their tongue to move things back to the pharynx, so things need to go far enough in the babies mouth so that it shoots back into the pharynx

question again

A; -the O2 sat is 89% and the baby is 5 min old and it can take the baby 5-10 min bc to get up to 95% -there is nothing indicating that we need to do a deeper suction on the baby

Interventions

•Protective Equipment: -Current health care trends and the focus on nonseparation of mothers and babies (rooming-in) have prompted some hospitals to abandon having a separate newborn nursery -In the mother/baby model of care, the infant stays in the mother's room, which reduces the need for a separate nursery -provision of a protective environment is basic to the care of the newborn •Environmental factors: -provision of adequate lighting, elimination of potential fire hazards, safety of electrical appliances, adequate ventilation, and controlled temperature and humidity •Infection control factors: -adequate floor space to permit the positioning of bassinets at least 3 feet apart in all directions, hand hygiene facilities, and areas for cleaning and storing equipment and supplies -Only specified personnel directly involved in the care of mothers and infants are allowed in these areas, thereby reducing the opportunities for the transmission of pathogenic organisms -Proper hand hygiene is essential to prevent the spread of health care-associated infection -wear gloves when handling infants until blood and amniotic fluid have been removed from the skin, when drawing blood (e.g., heelstick), when caring for a fresh wound (e.g., circumcision), and during diaper changes -Visitors such as siblings and grandparents are expected to perform hand hygiene before having contact with infants or equipment -Individuals with infectious conditions are excluded from contact with newborns or must take special precautions when working with infants. This group includes people with upper respiratory tract infections, gastrointestinal tract infections, and infectious skin conditions. •Preventing infant abductions: -many units have special limited-entry systems -Nurses teach mothers and their families to check the identity of any person who comes to remove the baby from their room -some units all staff members wear matching scrubs or special badges -Other units use closed-circuit television, computer monitoring systems, fingerprint identification pads, or infant bracelet security systems that alarm if the newborn is separated from the mother or is taken outside the boundaries of the unit •Preventing newborn falls -Most falls occur when the mother falls asleep while holding the newborn in her bed or in a reclining chair, although some falls occur at birth or when the infant is transported -Infants who fall, even from low level surfaces such as beds or chairs, are at risk of sustaining head injury that can include skull fracture -identifying risk factors such as maternal medications (e.g., opioids) that cause drowsiness and can increase the risk of the mother falling asleep while holding the infant -Parents should be instructed to place their newborn in the supine position in the bassinet for sleep -Bed-sharing is a controversial topic because some believe it promotes bonding, parents need to be aware of potential risks related to this practice -Parents using a nonjudgmental approach may increase the likelihood that a parent will report a newborn fall •Immunizations -Hepatitis B (HepB) vaccination is recommended for all infants before discharge -obtains parental consent and notes the mother's HepB status -at highest risk for contracting HepB are those born to women who have HepB or whose HepB status is unknown -If the mother is positive for HepB, the infant should receive the HepB vaccine and HepB immune globulin (HBIG) within 12 hours after birth -they start in the hospital- the only one they do is the Hep B. If mom is Hep B positive, the baby will get a vaccine and a immunoglobulin. -these are things you do to protect the newborn

Nutrient Needs

•Fluids -neither breastfed nor formula-fed infants need to be given water, not even those living in very hot climates -Breast milk contains 87% water -Feeding water to infants can decrease caloric consumption at a time when they are growing rapidly -Infants have room for little fluctuation in fluid balance and should be monitored closely for fluid intake and water loss •Energy -require adequate caloric intake to provide energy for growth, digestion, physical activity, and maintenance of organ metabolic function -Human milk provides an average of 67 kcal/100 ml or 20 kcal/oz -portion of the milk provides the greatest amount of energy -formula contains 20 kcal/oz, although the composition differs among brand •Carbohydrates -should provide at least 40% to 50% of the total calories in the diet -primary carbohydrate in human milk and commercially prepared infant formula, lactose is the most abundant carbohydrate in the diet of infants up to age 6 months -breakdown and absorption also increase calcium absorption -Oligosaccharides, another form of carbohydrate found in breast milk, are critical in the development of microflora in the intestinal tract of the newborn -promote an acidic environment in the intestines, preventing the growth of gram-negative and other pathogenic bacteria, thus increasing the infant's resistance to gastrointestinal (GI) illness •Fat -provide a major energy source for infants, supplying as much as 50% of the calories in breast milk and formula -fat content of human milk is composed of lipids, triglycerides, and cholesterol; cholesterol is an essential element for brain growth. -contains the essential fatty acids (EFAs) linoleic acid and linolenic acid and the long-chain polyunsaturated fatty acids arachidonic acid (ARA) and docosahexaenoic acid (DHA) -Cow's milk contains fewer of the EFAs and no polyunsaturated fatty acids -formula companies add DHA to their products, although there is a lack of evidence supporting the benefit -Modified cow's milk is used in most infant formulas, but the milk fat is removed, and another fat source such as corn oil, which the infant can digest and absorb, is added in its place •Protein -protein requirement per unit of body weight is greater in the newborn period than at any other time of life -**Human milk contains the two proteins whey and casein in a ratio of approximately 70:30 compared with the ratio of 20:80 in most cow's milk-based formulas -whey-to-casein ratio in human milk makes it more easily digestible and produces the soft stools seen in breastfed infants. -whey protein in human milk is high in essential amino acids needed for growth (whey protein is much easier to digest than casein; so breastmilk is much easier to digest and move through the babies system bc it has more whey, and a lot of water in it; formula is not as easily digested) -whey protein lactoferrin in human milk has iron-binding capabilities and bacteriostatic properties, particularly against gram-positive and gram-negative aerobes, anaerobes, and yeasts -casein in human milk enhances the absorption of iron, thus preventing iron-dependent bacteria from proliferating in the GI tract -amino acid components of human milk are uniquely suited to the newborn's metabolic capabilities •Vitamins -human milk contains all of the vitamins required for infant nutrition, with individual variations based on maternal diet and genetic differences - except vitamin d* -Vitamins are added to cow's-milk formulas to resemble levels found in breast milk -Vitamin D facilitates intestinal absorption of calcium and phosphorus, bone mineralization, and calcium resorption from bone -all infants who are breastfed or partially breastfed should receive 400 International Units of vitamin D daily, beginning the first few days of life -the only think not in breastmilk is vitamin D, so you do need o supplement that** •Minerals -mineral content of commercial infant formula is designed to reflect that of breast milk -Minerals are typically highest in human milk during the first few days after birth and decrease slightly throughout lactation. -ratio of calcium to phosphorus in human milk is 2:1, an optimal proportion for bone mineralization -cow's milk is high in calcium, the calcium-to-phosphorus ratio is low, resulting in decreased calcium absorption -Consequently young infants fed unmodified cow's milk are at risk for hypocalcemia, seizures, and tetany -calcium-to-phosphorus ratio in commercial infant formula is between that of human milk and cow's milk Iron levels are low in all types of milk; however, iron from human milk is better absorbed than iron from cow's milk, iron fortified formula, or infant cereals: -Breastfed infants draw on iron reserves deposited in utero and benefit from the high lactose and vitamin C levels in human milk that facilitate iron absorption -Full-term infants have enough iron stores from the mother to last for the first 4 months -After 4 months of age, infants who are exclusively breastfed are at risk for iron deficiency -AAP recommends giving exclusively breastfed infants an iron supplement (1 mg/kg/day) beginning at 4 months and continuing until the infant is consuming iron-containing complementary foods such as iron-fortified cereals -Formula-feeding infants should receive an iron-fortified commercial infant formula until 12 months of age -do not need to know how much of carb need to be in the diet, it is just showing what babies need and what will help them grow the -know breastmilk is a lot of water (87% of water) formula is not that much -you do not need to supplement outside of formula or breastfeeding milk( like do not need to give baby water bc there are no nutrients to it) -human milk and formula milk have about the same calories...

Neuromuscular

•Growth of brain -Follows predictable pattern -Becomes more gradual during remainder first decade -End of 1st year, cerebellum ends growth spurt •Glucose and oxygen -Glucose needed for energy -Careful assessment -Oxygen for metabolism •Spontaneous motor activity -Transient tremors of mouth and chin, and of arms and hands -Tremors are normal but should not be present when infant is quiet or persist beyond 1 month •Posture -Flexion of arms at elbows and legs at knees -Hips abducted and partially flexed -Intermittent fisting of hands is common -Muscle tone and strength are related -Normal should have resistance to passive movement (pulled to site or arm extended by exam) -Hypotonic should little resistance, like rag doll •Reflexes Sucking/rooting: -Touch infant's lip, cheek, or corner of mouth with nipple or finger -Infant turns head toward stimulus and opens mouth Palmar grasp: -Place finger in palm of hand -Infant's fingers curl around examiner's fingers -response lessens by 3-4 mo Plantar grasp: -Place finger at base of toes -Toes curl downward -response lessens by 8 mo Tonic neck: -With infant in supine neutral position, turn head quickly to one side -With infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures -Responses in leg are more consistent -Complete response disappears by 3-4 mo Moro: -Hold infant in semisitting position, allow head and trunk to fall backward to angle of at least 30 degrees (with support). -Place infant supine on flat surface; perform sharp hand clap -Symmetric abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement -cry may accompany or follow motor movement -Legs may follow similar pattern of response -Preterm infant does not complete "embrace"; instead arms fall backward because of weakness -Response is present at birth -complete response may be seen until 8 wk -body jerk only is seen between 8 and 18 wk -response is absent by 6 mo if neurologic maturation is not delayed Babinski: -On sole of foot, beginning at heel, stroke upward along lateral aspect of sole; then move finger across ball of foot -All toes hyperextend, with dorsiflexion of big toe—recorded as a positive sign -Absence requires neurologic evaluation -watch the khan academy neonatal reflexes video. -understand the reflexes that may be permanent and what we have and the ones that should go away. Do not need to know the time frames, just know if the baby is doing a reflex or not, if that is normal for them.

Changes by Systems

•Involution: uterus going back down to its normal size; before pre-pregnancy it is like the size of a fist and it is way down in the pelvis and has to get down to that point, so the term for that is called uterine involution. Involution begins immediately after the 3rd stage is over (right after that placenta is delivered). -Subinvolution: when the uterus is not going down as we would expect, and it is one of the causes of postpartum hemorrhage. -The uterus pretty much follows an expected involution process. Immediately after baby is delivered, if your were to palpate thee fundus, it would be about 2cm below the umbilicus. -Over the course of that first several hours postpartum, it may rise a little bit to it's highest, about 1 cm above the umbilicus. -But by 24 hours postpartum it should definitely be at least at the level of the umbilicus, and no higher. -After that first 24 hours, we typically see it go down about 1 to 2cm per day. If the uterus was at the umbilicus at 12 hours postpartum, that is totally fine, because were not worried about it going down too fast, we are worried about it not going down fast enough. So if it is lower than expected, that's a good thing and means it is doing what it's supposed to do. -When the placenta comes off of the uterine wall and it delivers, a raw placental site is left there (almost like an open wound). And remember all the blood flow that was going into the uterus and to that placenta, and so now that the placenta is gone, it is raw and wants to bleed. So, the uterus and all this muscle tissue begins to contract and the contractions basically act like a tourniquet for the bleeding, so all the muscle of the uterus will squeeze and will get firm and squeeze off al the blood vessels and will control the bleeding that way. •Contractions -The uterus will begin contracting after the placenta delivers bc we want it to be firm and feel very hard. -"Afterpains" -"Afterbirth cramps" -the multiparous women typically experience this more. The reason for that is they have had 2,3,4 babies and their uterus has been stretched several times and it just doesn't have the tone that it used to have and so the uterus has to work harder and contract harder to restore that tone. And this typically it gets worse with each baby. -There are certain things that are given after the 3rd stage of labor that can make the cramping worse: -There are meds such a Pitocin that they give after thee placenta is delivered which makes the cramping worse, but they do it to jumpstart the uterus to contract. -Breastfeeding in the immediate postpartum period also increases the cramping (which is uncomfortable but a good thing bc it helps to control the bleeding) -Lochia: Postpartum women also have some postpartum vaginal discharge. As the placenta site heals, it will still continue to bleed some, so just like involution the postpartum vaginal discharge (called lochia) should follow a pretty standard pattern and what we would expect to see. It can last anywhere from 4-6 weeks. It starts out the at its heaviest immediately after delivery and the first several hours and should start lightening up a little bit each day and start to taper off. But, many women will have some discharge up to the 4-6 mark (it gets lighter, but will still be there a little bit bc until the placenta sight is completely healed, there will be some bleeding still. Once that discharge stops, that is kind of how we know that site on the inside of the uterus has fully healed. -Also the lochia comes out more like a trickle and kind of like a period, and it is not spurting. -Lochia rubra (first 3 days)- dark red (a lot like a period) -Lochia serosa (4-10 days)- brownish red (kind of the color of old blood) and transitioning into a pink. -Lochia alba (10 days up to 4-6 weeks)- yellowish white discharge. -In general things that would be concerning: an increase in lochia and the flow would not be normal bc we expect it to decrease. Also, a persistence of the darker red (rubra) would not be normal (and there can be some problems such as some fragments of retained placenta inside, etc. that is causing her uterus to not go down like it should and causing a persistence of that rubra and that would not. be normal) -Usually in a C-section, the surgeon can suction out a lot of this discharge so they won't have nearly as much lochia as a woman that delivered vaginally. -Table 20.1 on pg. 418 •Cervix- the cervix goes through a lot, and especially if the mother delivered vaginally, so that cervix has stretched and thinned and needs to return back to normal. The cervix after delivery will begin to regain its tone, firm back up, and by about a week postpartum, the cervix will be back to 1 cm dilated. The cervix at delivering vaginally really never goes back to what it looked like before birth. (Cervix that has never had a baby looks like a donut with a small round opening in the middle of it. After you have had a baby, the cervix more looks like a slit shape.) •Vagina- the vagina will also gradually regain its tone, it will decrease in size (remember during pregnancy, it had lengthened so now it goes back down and decreases in size). -Women who are breastfeeding will experience some vaginal dryness, for pretty much as long as they are breastfeeding, which isn't problematic for the first 6 weeks postpartum, but once she starts becoming sexually active again, that can become more of a problem and can cause dispareunia or pain with intercourse. The reason for the vaginal dryness is due to the prolactin hormone (they have really high levels of this during breastfeeding); the prolactin basically puts the ovaries to sleep while she is breastfeeding, so we don't have all the estrogen production from the ovaries during that time and it is estrogen that makes the vaginal tissues moist, so that is why it is a common problem for breastfeeding women (but nothing that a water soluble lubricant can't fix) but we teach them to expect this. •Perineum: After delivery the perineum, and vaginal introitus will lot very red, swollen, and you may even see some hemorrhoids if a women has been pushing for a long time (like 2 or 3 hours). If the woman had an episiotomy or a laceration that was repaired, you would also note and see that. (most commonly, women will have 1st or 2nd degree lacerations, they should heal in about 2 or 3 weeks but if mom has a 3rd and 4th degrees, it may take up for several months for it to heal.) Those that have aa 4th degree tear, they basically have 2 holes that turn into one and for years, they can have issues with fecal incontinence for issues with gas and sexual problems with pain. •Pelvic muscles: the pelvic floor muscles can really be damaged during childbirth, they can be stretched also, and a lot of the time the patient will not notice this for many years to come, and this is not something that would have an immediate effect. A lot of times when women become menopausal years later after giving birth, and the tissues lose the protective effect that estrogen has, then suddenly they start to experience the consequences of the damage that was done to their pelvic floor. Women will experience urinary incontinence, uterine prolapse where their uterus is basically trying to fall out, etc. So, we recommend and encourage Kegel exercises in the postpartum period •Return of ovarian function -Prolactin: immediately after the placenta i delivered (remember it was the source of all of our hormones), there will be a huge drop in estrogen and progesterone and that will signal prolactin to rapidly increase in right after delivery and over the the first week or so after and they will continue to keep going up because that is the hormone that tells her body to make milk. This process happens in all women, regardless if they breastfeeding or not. -Those that do not breastfeed their prolactin levels, after that initial rise, their prolactin levels go back down if they are not breastfeeding. But if they are breastfeeding and as long as they continue to, those prolactin levels will stay elevated. How long and how often she breastfeeds influences how high those prolactin levels get. As long as the prolactin is high, it basically puts the ovaries to sleep, and a lot of the time, the woman can go a year without a period if she is breastfeeding that whole time. Or if mom starts supplementing and not breastfeeding as much if she goes back to work or something, those prolactin levels may decrease some and that may start her period again. -Return of menses: -As long as the prolactin is high, it basically puts the ovaries to sleep. -If a mom is breastfeeding exclusively, every 2 or 3 hours and not supplementing, and a lot of the time, the woman can go a year before their periods return since their ovarian function is suppressed during that time. -If mom were to start supplementing and not breastfeeding as much if she goes back to work or something, those prolactin levels will decrease some and that may start her period again and her ovaries may wake up -Ovarian function and periods will come back sooner in woman who are not breastfeeding. For those who are not breastfeeding, their ovarian function can return and they can ovulate as soon as 4 weeks after delivery, which means by about 6 weeks after delivery, they could be having their first period after giving birth. -The first period after giving birth is usually a rough and heavy period which is expected and we can warn women about, but after a few cycles their period will go back to what they were usually like. •Breasts -There is a little change 1st 24 hours (to the way they look and feel, however there are hormonal changes that are going on with those prolactin levels where they are rising) -They should be able to hand express some colostrum (remember colostrum is present starting as early as the 2nd trimester), and over the course of the first couple of days, the breasts will gradually feel more full and that is as the colostrum transitions to mature breastmilk. Breastfeeding vs. Non-breastfeeding -Pretty much all mothers will experience breast engorgement, and it is pretty universal whether the woman is or isn't breastfeeding. Engorgement is caused by not only by an increase in milk, but also an increase in blood flow and increase in lymphatic flow so that is the reason for discomfort. With engorgement, breast will get very warm, firm, and tender. This phenomenon usually happens at anywhere from 3-5 days postpartum. -For women who have chosen not to breastfeed, the prolactin levels will begin to decline because she is not stimulating the breasts and usually within 24-48 hours (usually about that amount of time off pretty extreme discomfort) of getting engorged, it will go away. -As long as a breastfeeding mom keeps breastfeeding, her breasts will kind of balance out and realize how much she needs. They can still get engorged even after the initial week (so if they go too long without feeding baby or pumping, or try to sleep all night without pumping, they will wake up very engorged because their breasts have filled up a lot). -Also for the moms who are not breastfeeding, we do not want them to stimulate the breasts since it would stimulate milk production. So, although engorgement is really uncomfortable, they may want to just to get rid of the feeling but make sure they don't. Some things we can do for these non-breastfeeding moms being engorged is they can bind the breasts up with an ACE wrap to make them more comfortable since they won't move, or a tight sports bra can help. They can use pain relievers like Motrin or Tylenol. You can also put raw cabbage leaves and put them in bra to help relieve the discomfort of engorgement. Ice packs also help. •Cardiac ▫Blood volume -How did pregnancy affect blood volume? There was significant increase in blood volume and that sets woman up to be able to tolerate blood loss lost during labor. bc it is a protective effect. -We would allow more blood loss with a C section than a vaginal delivery -EBL (or estimated blood loss) is 300-500mL for a vaginal delivery. For a c section, the EBL is 500- 1000mL of blood. So we would allow a C section patient to lose up to 1L of blood before we get concerned. ▫Cardiac output -How did CO change during pregnancy? It increased during pregnancy. -Immediately after delivery, there is a lot of fluid shifting going on mainly bc the woman had this utero-placental circulation during pregnancy and once the cord is cut, all of the volume goes to the maternal circulation and so for the first hour or 2 after delivery, her CO will increase even more than what it was during pregnancy, so the heart is having to work harder essentially. So we need to think about how that would effect someone with cardiac issues already and how this further increase of CO and workload could affect their heart. ▫Pulse and blood pressure: the pulse will increase to also account for this fluid shifting and increase in CO and workload. Her BP will increase slightly. The slight increase in BP can be seen in the first few days postpartum. -Postpartum women can also get a lot of orthostatic hypotension due to the fluid shifting so they are prone to getting up and getting light-headed. ▫Labs -H/H: we expect to see a slight to moderate drop in H&H because she is bleeding and we will see it in the first couple of days until she repletes. A lot of times women postpartum will stay on that prenatal vitamins that has all the iron in it to help boost the blood volume back up after they have lost some. -WBC: childbirth is pretty stressful to the body, and so the body kind of reacts to that and so it is normal to see an increase in the WBC count as high as 30,000 and still be considered normal due to stress response (normal is 4,500 to 11,000). But, this rise can cover up infection (so you cannot just assume it is the stress of childbirth, so you still need to assess for signs of infection and checking for fever, listen to lungs, check her laceration site, check if we have foul smelling lochia, etc.) -Clotting factors increased in pregnancy, so they will remain increased for about 6 weeks postpartum, so women are still at risk for VTE in the postpartum period. -Most women are usually sitting around with this new baby, and also a lot of moms are obese, and if the patient has had a c section and this major surgery, it will probably make sure at more risk for a DVT or potentially a PE bc she is immobile even more. •Urinary ▫Urine output: all of the fluid that we have needs to fget out of the body, so women, in the first few days of the postpartum period will experience a pretty massive diuresis to get rid of all that fluid (it is not abnormal for women to put out about 3,000mL/day for the first few days) ▫Bladder distention: this increase in urinary output is coupled with the fact that see may have some swelling and trauma down there, making it harder to pee, she has been anesthetized and may take some time for the bladder to wake up, so sometimes they don't feel the urge or need to pee, so this decreased urge coupled with increase urine output creates the potential for bladder distention. This bladder distention and having a full bladder can cause postpartum hemorrhage so we really need to keep an eye on the bladder to make sure that these things don't occur. •Gastrointestinal -By the time women get to the postpartum floor, they are usually starving and had nothing to eat during the whole labor process, and prob not a lot to drink either. Also, in labor their gut is not part of the body that is worried about working then so they have decreased peristalsis while in labor, they are on pain meds, possibly narcotics, or possibly general anesthesia which further slowed it down so it sets us up for constipation, which is a fairly common problem in postpartum. It is normal for it to take 2-3 days for her to have her first bowel movement after birth because of that. Having their first bowel movement also poses a lot of anxiety and fear for women bc they are tender and may have stitches or hemorrhoids down there, so a lot of times stool softeners will be continued into the postpartum period. •Neurological ▫Headaches:They are pretty common and a lot of times they are perfectly normal because mom's are exhausted and not sleeping much in the hospital which can be a reason for the headache, but you have to keep in mind there are some more problematic causes for the headache as well. They can have a spinal HA after an epidural or spinal if there CSF leaking where that puncture site was and they just need to like flat on their back and may have to do a blood patch where they draw the patients blood and inject it at the site and clots it off. An even more ominous postpartum HA can be due to preeclampsia (that can first show up postpartum) so you need to keep this in mind if patient is complaining of a new onset headache. •Musculoskeletal ▫Abdominal wall- It is very normal to still look pregnant for a few weeks. The abdominal muscle tone will gradually return and how quickly their abdomen goes back to normal kind of depends on how strong their muscle tone was prior to pregnancy. -Diastasis recti: This is the separation in between the ab muscles and it may improve some, but may persist forever not go back completely to normal and will always be able to feel the soft mushy area in between their abs. -the Joints (especially the hip and pelvis) that were relaxed during pregnancy, most of it will go back to normal. One of the things that do not go back to normal is if their feet got wider and bigger because it also relaxed during pregnancy, their feet will not go back to normal and they will stay with the 1/2 size (just an example) up shoe.

Complications of the PP Period: Postpartum Hemorrhage (PPH)

•Leading cause of maternal morbidity and mortality in the US and worldwide •Diagnosing a PPH -how we diagnose depends on if it was a vaginal or c section delivery-SVD (spontaneous vaginal delivery)- more than 500 mL would be considered a hemorrhage vs. C/S blood loss- more than 1,000 mL (or 1L) would be considered a hemorrhage. that is one reason why it is important to weigh the blood loss. -Lab changes: check H&H after delivery and compare to the admission H&H. (bc if she came in and was a 10 and after delivery is a 7, that would be pretty worrisome. •Early PPH: will occur within the first 24 hours (we know the greatest time is within the first couple of hours is when most of them happen) •Late PPH: anywhere after the 24 hr mark and before the 6 week mark. -The causes of early and late PPH are a little different. •Risk Factors/ Causes -Uterine atony: the most common cause of early PPH -Unrepaired lacerations of the genital tract- whether cervix, vagina, perineum, etc. -Retained Placental fragments: common cause of late PPH -Inversion of the uterus: rare complication and why we anchor the uterus when we massage it. -Uterine subinvolution: another cause for late PPH -Chorioamnionitis/endometritis: common for a late PPH -Magnesium sulfate during labor or PP: since it is a smooth muscle relaxant, the effects will counteract what we want the uterus to do (we want it to contract) but on Mag, it may cause it to stay relaxed or boggy -Coagulation disorders: bc if they don't have the clotting factors, they can't clot. Uterine Atony ▫Risk factors: -Overdistended uterus: things that can cause this is a big baby, polyhydramnios, and multiples which can make the uterus really stretched and extra distended, and it is not able to contract as well after that. -Multiparity/grandmultiparity: multiple babies or more than 5 babies bc the uterus doesn't have the tone it used to have so it is harder to contract. -Full bladder: intervenes with contraction -Retained placental fragments: if some is still left in there, it still interferes with the ability for the uterus to contract. -Use of magnesium sulfate: counteracts what the uterus needs to do. -Rapid and/or prolonged labor: in either case, the uterus is tired so it does not have a lot of tone and won't contract very well. -Chorioamnionitis: any time the uterus is infected or sick, can't contract well. -Induction/augmentation of labor with oxytocin: if someone was given oxytocin for these reasons to make the contractions be stronger, they are more at risk for a boggy uterus and bleeding bc oxytocin is hard on the uterus and makes it tired (even though it is also the opposite) If we suspect a PPH, we first thing we need to do is: •Assessment -Evaluate contractility of the uterus and check the fundus -Visual or manual inspection of perineum/vagina/uterus (we would do this if we feel the uterus and it is firm or hard, however she is continuing to bleed a lot, and could be due to an genital tract laceration) •Management/Treatment of PPH due to uterine atony -First step: MASSAGE THE FUNDUS when it is boggy -Evaluate/eliminate bladder distention (this is the 2nd thing you would do)- if the bladder is pushing up on the the uterus and causing it to deviate off to the side, we would need to straight cath and get rid of that urine, bc it is most likely a bladder issue so we would do that first). -IV oxytocin (Pitocin) in LR or NS: if she is not already on it) -Other medications to increase uterine tone: Methergine:/Hemabate/Cytotec (if she is already on Pitocin and still bleeding). All 3 of the drugs cause the uterus to contract. Methergine and Hemabate can both be given IM so can be given quickly; they can also be given directly in the uterine muscle for quick action. Methergine and Hemabate is contraindicated in women with HTN (including gestational HTN or preeclampsia) . Hemabate is also contraindicated with asthma. (hemabate=intubate is a way you can remember that). Cytotec is usually given rectally so it can work quickly. -Supplemental O2 (bc if she starts to lose a lot of blood, her pulse ox would drop and would put her on a non-rebreather mask) -IVF/Blood administration -Bimanual compression by OB/midwife: they put one fist inside of the uterus and one hand on the abdomen and act like a tourniquet -Surgical intervention (if they have tried all of these other things). The worst case scenario is she may need a hysterectomy and that might be the only thing to do to stop the bleeding. •Uterotonic drugs to manage PPH-p. 725 (actions, side effects, contraindications** important to consider this , nursing considerations)*- look at this Retained placental fragments (another cause of hemorrhage) -Can result in uterine atony -Symptoms: excessive uterine bleeding with soft uterus Management/Treatment: -Manual removal of placenta by practitioner -Dilation & Curettage (D&C) in the OR -IV oxytocin to promote uterine contractility when placenta removed Lacerations of the Genital Tract -can be perineal, vaginal, or cervical -Should be suspected if there is excessive bleeding with a firm uterus -May be a slow trickle or frank hemorrhage -Management/Treatment: needs to be repaired. Hematomas -if mom is complaining of pain really severe, even after pain meds, it would prompt us to think they may have this. -Collection of blood in connective tissue -Vulvar (most common kind- this is the only kind that you be able to visualize), vaginal, or retroperitoneal (rare but can be life-threatening bc the collection of blood can be so large that they go into a hemorrhagic shock) -Pain is most common symptom* -Persistent perineal or rectal pain -Feeling of pressure inside vagina -Usually surgically evacuated: have to slice into it and relieve the pressure Uterine Inversion -Can invert completely out of the introitus or partially through the cervical os (it is why we anchor to massage the uterus) and when that happens, lots of bleeding happens Causes: -Manual extraction of the placenta -Excessive traction on the umbilical cord with placental delivery (when they are pulling it out too soon and it is not detached yet) -Uterine atony -Aggressive fundal massage -Fundal attachment of placenta Signs: sudden signs of bleeding and shock. They can use a lot of blood when this happens, Also, if it has flipped, you would be not able to palpate the fundus anymore. Treatment- EMERGENCY! -the OB provider has to manually or surgically replace it. Subinvolution -inability of the uterus to go back down -Cause of late PPH -Can be caused by infection or retained placental fragments (retained fragments can cause a short or late PPH) Signs: she will continue bleeding, may be a week or two out and still have lochia rubra. Treatment: depends on the cause: -Antibiotics if infection suspected -Methergine (uterotonic drug, if mom does not have HTN) -Dilation and Curettage (D&C) to remove retained fragments, if we suspect that.

A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? 1. Expiratory grunting 2. Inspiratory nasal flaring 3. Apnea for 10 second periods 4. Obligatory nose breathers 5. Crackles and wheezing 6. Bluish color to lips 7. Respiratory rate of 52

3 (abnormal is greater than 20 seconds) 4 (if something obstructs their nose, they will open their mouth up but it is jus not their natural breathing) 7 -grunting is never okay -fine crackles are normal b they still may have some fluid in their; wheezes though are not normal. With course crackles, you may hear it with a c section baby, but with vaginal delivery you won't because in a vaginal delivery, it is being squeezed out and the pressure helps expel some of the fluid, and in a c section baby, they can't get the fluid out as well, but the course crackles should go away soon after.

A nurse is performing a neurologic assessment on a 1 day old neonate in the nursery. Which findings would indicate possible asphyxia in utero? 1. The neonate grasps the nurse's finger when put in the palm of the neonate's hand 2. The neonate does stomping movements when help upright with the sole of the feet touching the surface. 3. The neonate displays weak, ineffective sucking 4.The neonate does not respond when the nurse claps her hands (moro) 5. The neonate turns toward the nurse's ... 6. The feet do not flare out when the feet are touched. (babinski)

3, 4, 6

The nurse completed discharge teaching with new parents who are bottle-feeding newborn. Which statement by the parents indicates successful teaching? 1. "Our baby will require feedings through the night for the first week after birth" 2. "The baby should burp during and after each feeding with projectile feeding 3. "Our baby should have at. least one soft, formed stool per day" 4. "We should weigh our baby daily to make sure he is gaining weight"

Answer: 3 1 is wrong bc you will be feeding way longer than that 2 is wrong bc no baby should be vomiting, spit up is normal though 3 is right (breastfed babies have 1-3 looser stools and they are yellowy (bc it is easier to digest). Formula fed stools -we should have 1 a day and are more. pasty, pinky, putty look and more formed). The goal is to have 2 stool per day. 4 is not necessary to weigh baby daily; if there was a concern you would see the pediatrician or have a lactation counselor seen.

When the mother of a new baby asks the nurse to feed her baby, the most appropriate response is to say: 1. "I'll feed him today. Maybe tomorrow you can try it" 2. "It's not difficult at all. He is just like a normal baby, only smaller" 3. "You can learn to feed him as well as I can; I wasn't good when I first fed a premature infant either" 4. "it's frightening sometimes to feed an infant this small, but I'll stay with you to help"

Answer: 4

Question

B; We are at 1 min after birth and have just done the Apgar check, so the next most important thing is skin to skin.

Choosing a Feeding Method

Breastfeeding •Natural extension of pregnancy/childbirth: it is much more than simply a means of supplying nutrition -unique bonding experience between mother and infant that is characteristic of breastfeeding -tend to select the same method of infant feeding for each of their children •Partner/family support -Women who perceive their partners to prefer breastfeeding are more likely to breastfeed -more likely to breastfeed successfully when partners and family members are positive about breastfeeding and have the skills to support it -in the Hispanic culture breastfeeding is the norm, whereas formula feeding is more common among African-American families •Mother's knowledge -about the health benefits to the infant and her comfort level with breastfeeding in social settings -relationship between maternal weight and infant feeding decisions -Women who are overweight or obese are less likely to breastfeed than women who are underweight or of average weight •Barriers -lack of broad social support for breastfeeding and the widespread marketing by infant formula companies -lack of prenatal breastfeeding education for expectant parents and insufficient training and education of health care professionals about breastfeeding -lack of support for breastfeeding mothers during the first 2 to 3 weeks after birth, when they are most likely to encounter difficulties -major obstacle for women is employment and the need to return to work after birth -Other common barriers include lack of comfort or uneasiness with breastfeeding, pain, lifestyle incompatibility, discomfort with public breastfeeding, and a lack of formal support •Formula feeding -Parents who choose to formula feed often make this decision without complete information and understanding of the benefits of breastfeeding -Cultural beliefs and myths and misconceptions about breastfeeding influence women's decision making -Many women see bottle feeding as more convenient or less embarrassing than breastfeeding formula feeding as a way to ensure that the father, other family members, and daycare providers can feed the baby -lack confidence in their ability to produce breast milk of adequate quantity or quality -see breastfeeding as incompatible with an active social life, or they think that it will prevent them from going back to work -Modesty issues and societal barriers exist against breastfeeding in public. Contraindications Newborns -Galactosemia (meaning baby is allergic to something in the breastmilk) Mothers -Positive for human T cell lymphotropic virus types I/II -Untreated brucellosis -Active tuberculosis -Active herpes simplex lesions on the breasts -HIV infection Active TB or Herpes -Only contraindicated for infant to be placed to breast, mother can still express milk and feed -Women with TB can feed once treated for at least 2 weeks and deemed noninfectious HIV- Contraindication in US -Where HIV is prevalent, benefits outweigh risk of contracting HIV from infected mothers -support the mother no matter what she chooses, there is not wrong decisions. Remember that religious, cultural, ethnic facters play into this decision of breastfeeding or bottle feeding.

The nurse is assigned to care for a 2 hour old newborn in an Isolette. She checks the temp of the Isolette and knowing the temp is too high if the infant:

-Temperature is 101 degrees rectally.

BUBBLEHE Assessment for a postpartum patient

•B = Breast •U = Uterus •B = Bladder •B = Bowel •L = Lochia (or bleeding) •E = Episiotomy/Laceration •H = Homan's/Hemorrhoids (homan's assesses for DVT's) •E = Emotional -This is the focused assessment for a postpartum patient. We will still me doing to the full head to toe every shift but this is what wee will focus on throughout the day.

Laboratory and Diagnostic Tests

•Universal newborn screening: -newborn genetic screening is an important public health program aimed at early detection of genetic diseases that result in severe health problems if not treated early -program is state-based and involves a variety of components including education, screening, follow-up, treatment, and a system for monitoring and evaluation -recommends screening for 31 core disorders and 26 secondary disorders; core disorders include: -hemoglobinopathies (e.g., sickle cell disease) -inborn errors of metabolism (e.g., phenylketonuria [PKU], galactosemia -severe combined immunodeficiency -critical congenital heart disease -most current list is available through the National Newborn Screening and Genetics Resource Center -Capillary blood samples are obtained from newborn infants using a heelstick -blood is collected on a special filter paper and sent to a designated state laboratory for analysis -usually collected in the hospital after 24 hours of age and before discharge -test should be repeated at age 1 to 2 weeks if the initial specimen was obtained when the infant was younger than 24 hours •Newborn hearing screening -Hearing loss is the most commonly diagnosed genetic disorder of all the core conditions in the universal screening program -routine hearing screening for all newborns before hospital discharge or no later than 1 month of age -hearing screening provides information about the pathways from the external ear to the cerebral cortex -Initial screening is done with the evoked otoacoustic emissions (EOAE) test -Newborns who do not pass the initial screening test should have the hearing screening test repeated as part of follow-up care -If the infant still does not pass, a comprehensive audiologic evaluation should be done by 3 months of age •Screening for critical congenital heart disease (CCHD) -added to the uniform screening panel in the United States in 2011 -performed using pulse oximetry to measure oxygen saturation for the purpose of detecting hypoxemia -Pulse oximetry testing can detect some critical congenital heart defects that present with hypoxemia in the absence of other physical symptoms -Hypoxemia can be the first sign that a congenital heart defect is present and other symptoms can develop once the newborn has been discharged -Screening is performed at 24 to 48 hours of age -Oxygen saturation is measured in the right hand and one foot -A "passing" result is oxygen saturation of greater than 95% in either extremity, with a less than 3% absolute difference between the upper and lower extremity readings -Immediate evaluation is needed if the oxygen saturation is less than 90% -evaluated for hemodynamic stability and hypoxemia; an echocardiogram is usually performed -a lot of these are mandated by the state, and educate parents about the tests and why they are done

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? 1. Hypospadias 2. Hydrocele 3. Family history of hemophilia 4. Hyperbilirubinemia 5. Epispadias

1, 5 bc both are abnormal location of the meatus. 3 bc we would need to do testing to see if baby also has hemophilia before we do surgery 2 is a fluid filled testicle, but it is not a contraindication of a circ. 4 is also not a contraindication.

Things that put infants a risk for developing jaundice:

-breastfeeding can sometimes lead to breastfeeding jaundice bc it takes 3-5 days for real milk to come in and they are just getting colostrum. It is harder for babies to get used to breastfeeding; a big part of the nipple and areola need to be in. Bottles can be much longer and easier to get back to the throat and pharynx. -delayed cord clamping allows some of the blood from the placenta to the baby so that the baby has higher blood levels- so if we have higher levels of RBC's, they are breaking down a lot and quicker and therefore can lead to jaundice. The risk don't really outweigh the risk factors unless, there are reasons and risks for having jaundice. -Cord milking is when he provider is milking the blood from cord, back into the baby. -Bruising bc we have a buildup of RBCs.

A 24- year old primipara says "I am worried that I will not be able to breastfeed my baby because my breasts are so small" What is the best response? 1. Breast milk can be enhanced by occasional formula feeding 2. The woman's motivation to breastfeed is important 3. Because her breasts are small, she will have to feed the baby more often 4. Breast size poses no influence on a woman's ability to breastfeed a baby

4

The nurse is assisting a breastfeeding client when she asks how she will know if her baby is getting any milk. Which statements are the priority? 1. "An audible sound will be heard as your baby is swallowing breast milk" 2. "Appears content after feeding and sleeps 4 hours between feedings" 3. "Burps loudly once or twice between breasts and when finished" 4. "Finishing the feeding in 5 minutes on each breast" 5. "Urinates 6-8 times/day and 1-3 bowel movements after day 4"

Answer: 1, 5 2 is wrong bc should be feeding every 2-3 hours 3 if it had just said burps, then could be right but should not just have a number to it which makes it wrong, bc they could not burp at all or have 5 burps- it is the number in the answer choice that makes it wrong. 4 you need to feed for longer than just 5 min to get the hind milk.

Reproductive

Female -Increase in estrogen followed by drop after birth can result in mucoid vaginal discharge and/or bloody spotting (pseudomenstruation) -External genitalia usually edematous with increased pigmentation Male -Uncircumcised means foreskin or prepuce completely covers the glans -Foreskin adheres to glans and is not fully retractable until 3-4 years -Urethra should be at tip of penis -Closer to term infant is, the testes can be palpated in scrotum with rugae covering scrotal sac -Incidence of undescended testes is 3.7% in term males and 21% in preterm males Breast tissue -Occurs in both sexes by the hyperestrogenism of pregancy -Thin discharge, or witch's milk, can be seen -No significance, no treatment, will subside on own Signs of reproductive system problems Ambiguous genitalia: -Closely inspect for ambiguous genitalia or abnormalities -Female urethral opening should be behind clitoris, any deviation could suggest clitoris is small penis -Can occur with conditions such as adrenal hyperplasia -Fecal discharge from vagina-rectovaginal fistula and should be reported Hypospadias: Urethra on ventral surface of penis Epispadias: Urethra on dorsal surface -Report these along with undescended or maldescended testes.

At a 7 day checkup Charlie weighs 3250g. At birth, he weighed 3325g. What is the appropriate response when his mother questions his weight loss?

Say this is normal but inquire about how breastfeeding is going and offer encouragement. -Charlie lost (3325-3250=75); 3325/75= 0.022 so he lost 2.2% of his weight. -It is okay for a baby to lose 5-10%. It is fine for baby to lose less than 5%. You would be concerned if they lost more than 10%; and if they do lose weight, we will give them 10-14 days to regain their weight back.

Postpartum Depression

•Affects 10-15% of postpartum women •More serious than "postpartum blues" •Causes: -Can be biologic, psychologic, situational, or multifactorial (or predispositions to anxiety and depression) -Change in hormone levels (estrogen fluctuations) -Poor nutrition (lack of folate can contribute to lower serotonin levels and poor response to antidepressants) -it is likely r/t all of these factors •Risk Factors -anyone with any preexisting hx of anxiety, depression, or a history of PP depression in a prior pregnancy, women with preexisting mood disorders such as personality disorder, schizophrenia, bipolar disorder and it can worsen then, also not having any social support bc it can make someone feel overwhelmed quickly, unintended pregnancy, baby being sick and admitted to NICU, etc. Symptoms •Intense and pervasive sadness with severe mood swings •Irritability that flares up with little provocation •Disinterest in the infant and annoyance with care demands •Medical management: PP depression will improve over several months with meds and treatment, but will rarely go away on its own. First line tx is your SSRI's (Zoloft, prozac, etc.) also anti-anxiety meds and psychotherapy in conjunction with meds can be helpful. •Prevention techniques: you need to teach the mom and family all of those techniques we said for the PP blues.

When assessing the neonate's head, the following is noted. How does the nurse document this finding most accurately?

-cephalhematoma contained on the left side. It does not cross that suture line in the middle. (the caput can cross suture lines so that is how we know it is the cephal) -a kiwi, vacuum, or even forceps can cause a cephalhematoma. it can also cause the caput.

A graduate nurse is explaining how to assess newborn jaundice and the effects of phototherapy. Which statements are correct? 1. "Therapy treatment can increase the risk for dehydration" 2. "It is best to observe for jaundice in the conjunctival sac or oral mucosa" 3. "the neonate will be irritable from the elevated bilirubin in the system" 4. "I will monitor the unconjugated bilirubin carefully as it is the dangerous one" 5. "I will carefully record the neonate's intake as limiting fluids is helpful"

1- it does increase the risk for dehydration 2- these are good places to look and are correct, however there are other places as well 4-the unconjugated is the the dangerous one

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temp or 95.5 degrees, and apical pulse of 110 beats/min, and a respiratory rate of 64 breaths. minute. Which assessment would be most concerning for the nurse?

The temp bc the baby is hypothermic, and their temp is a lot worse than the respirations, and the RR is prob high due to the temp.

Assessment for Deep Vein Thrombosis

•Homan's sign: you have the patient bend their knee a little bit and have this dorsiflex their foot and if there is pain for that, then it would be a possible Homan's sign and that would suspect us to think they have a possible DVT. •Leg pain, increased size, redness, unilateral swelling, warmth •What should you do if you suspect a blood clot in your patient? You will elevate their leg (by elevating it helps the blood get back to their heart), and notify the provider. -PP they are at an increased risk for DVT bc they are more immobile, their clotting factors are increased r/t estrogen, possibly obesity, etc.

Bowel Function

•Risk for constipation (due to being on iron, opioid pain meds, in labor they don't eat or drink a lot so may be a little dehydrated, scared to go, immobility, anesthesia, may have hemorrhoids, and some patients are on magnesium that stay on it PP for preeclampsia and bc it is a CNS depressant and relaxes everything, it will relax the bowel, etc.) •Preventing constipation -Encourage fluids -Increase fiber -Ambulation (moving around frequently and early; this helps with bowel function and preventing clots) -Stool softener/laxatives (if not already on one, and if she was, continuing it) •Gas pains: C section patient will complain a lot more about gas pain so we can get her to ambulate which is the best way to help that. We can also get mom to avoid drinking through straws bc it can increase gas; also carbonation can make it worse so avoiding that as well.

A client has just delivered a healthy 7-pound baby boy. The physician instructs the nurse to suction the baby. The procedure the nurse uses is to: 1.Suction the nose first 2. Suction the mouth first 3. Suction neither the nose nor mouth until the physician gives further instructions 4. Turn the baby on his side so mucous will drain out before suctioning

2. Suction mouth first so that the baby does not aspirate on what is around their mouth. Then you will do both nostrils

Hematologic

•Red blood cells -Because fetal circulation is less efficient at oxygen exchange than the lungs, the fetus needs additional RBCs for transport of oxygen in utero -at birth the average levels of RBCs, hemoglobin, and hematocrit are higher than those in the adult; these levels fall slowly over the first month •Leukocytes -Leukocytosis, with a white blood cell (WBC) count of approximately 18,000/mm3 (range 9000 to 30,000/mm3), is normal at birth -number of WBCs increases to 23,000 to 24,000/mm3 during the first day after birth -initial high WBC count of the newborn decreases rapidly, -leukocytes are slow to recognize foreign protein and localize and fight infection early in life -leukocytes help to fight infection, and babies don't fight infection well if there were for bacteria or virus to get inside. •Platelets -Platelet count ranges between 150,000 and 300,000/mm3 -levels of factors II, VII, IX, and X found in the liver decrease during the first few days of life because the newborn cannot synthesize vitamin K -bleeding tendencies in the newborn are rare, and, unless the vitamin K deficiency is great, clotting is sufficient to prevent hemorrhage •Blood groups -determined genetically and established early in fetal life -Cord blood samples may be used to identify the infant's blood type and Rh status -** know the flowchart picture (know how the RBC breaks down)

When would be appropriate to complete baby Charlie's first physical exam? 1. At one hour, as soon as immediate care is completed 2. At 4 hours of age with an axillary temp of 98.8 3. At 36 hours of age upon discharge 4. At 4 weeks old

2; we wait a couple hours because bonding is the most important and the latest you want to feed the baby is at 1 hour of age. So, you want those things to happen first and then we would do a full physical assessment.

Of these 4 babies born at full-term at healthy, which has the bests chance of not getting sick? 1. Baby Will who is fed infant formula by bottle exclusively 2. Baby Baylee who is breastfed and is never given other liquids 3. Baby Hannah who is breastfed and is given sips of herbal tea (they don't need anything else, they just need the calories from the milk 4. Baby Evie who is breastfed with formula supplementation (even though formula has the nutrients, by using all of the bottles, nipples, etc. they are still at risk for getting sick

2; breast fed babies are the best way of not getting sick

In assessing a newborn infant, the nurse knows that postmature infants may exhibit: 1. Heavy vernix 2. Large size for gestation age 3. Increases subcutaneous fat, absent creases on feet 4. Small size for gestation age

4; just bc you have a postmature infant, does not mean they will be big. They are not having good blood supply anymore so they have lost and used some of their sub q cat already and that gives them a very thin look and that makes them small, bc the placenta wants to stop working when postterm.

Baby boy Tiger was delivered at 1012 am. After reviewing the EHR, wha is the nurse's initial action? 1. Suction the nose 2. Take the infant to the overhead warmer 3. Begin chest compressions 4. Vigorously dry the infant

4; you do this first to get it warm and to stimulate respirations

Thermogenic

**This is the 2nd most critical thing. We need to be able to breath, and we have to be born. -Understand how babies warm themselves and where the best place will be to stay warm. -As nurses, we want to provide a "neutral thermal environment" Thermoregulation -maintenance of balance between heat loss and heat production -first 12 hours after birth the neonate attempts to achieve thermal balance in adjusting to the extrauterine environmental temperature -Newborns have a thin layer of subcutaneous fat. -Newborns have larger body surface-to-body weight (mass) ratios than do children and adults -Drying the infant quickly after birth is essential to prevent hypothermia -Skin-to-skin contact with the mother enhances newborn temperature control and maternal-infant interaction Thermogenesis -In response to cold the neonate: The is an increase in metabolic rate, increase in muscle activity, peripheral vascular constriction and metabolism of brown fat. -Cold infants may cry and appear restless -Vasoconstriction causes skin to feel cool and see acrocyanosis -Increase in metabolic activity in brain, heart, and liver increasing oxygen and glucose consumption -Term newborns assume a position of flexion that helps guard against heat loss because it diminishes the amount of body surface exposed to the environment -Produce heat through nonshivering thermogenesis: -Metabolism of brown fat, which is unique to the newborn; and secondarily by increased metabolic activity in the brain, heart, and liver -Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. -The amount of brown fat reserve increases with the weeks of gestation. Heat loss: Evaporation: bath, amniotic fluid, dry the baby Conduction: heat to cool surface; cold hands or equipment Convection: loss to cooler air currents - keep room warm, away from air vents Radiation: transfer to cool object not in direct contact - cold walls or equipment or windows

Respiratory

**This is the most critical and immediate physiological change bc they need to figure out how to breath since they have only had breathing movements in utero- to take their first breath is a new concept for them. -Most babies are able to do this and don't usually have many problems, but occasionally can. Initiation of breathing: -all these factors play a role in starting the breathing process. •Chemical factors: -Decreased levels of oxygen and increased levels of carbon dioxide have a cumulative effect by stimulating the respiratory center in the medulla. -Another chemical factor may also play a role - as a result of clamping the cord, there is a drop in levels of a prostaglandin that can inhibit respirations. •Mechanical factors: -stimulated by changes in intrathoracic pressure resulting from compression of the chest during vaginal birth- infant passes through the birth canal, the chest is compressed. -With birth this pressure on the chest is released, and the negative intrathoracic pressure helps draw air into the lungs -Air enters alveoli replacing expelled amniotic fluid -Crying increases positive pressure created by crying helps keep the alveoli open and promotes expansion of the alveoli •Thermal factors: -profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla •Sensory factors: -handling the infant by the physician or nurse-midwife, suctioning the mouth and nose, and drying by the nurses- Pain associated with birth -lights, sounds, and smells of the new environment •Acrocyanosis: normal finding in the first 24 hours after birth Breathing Movements: -Once respirations are established, breaths are shallow and irregular -ranging from 30 to 60 breaths/minute -periods of breathing that include pauses in respirations lasting less than 20 seconds -episodes of periodic breathing occur most often during the active (rapid eye movement [REM]) sleep cycle -decrease in frequency and duration with age -Apneic periods longer than 20 seconds indicate a pathologic process and should be evaluated -Newborn infants are by preference nose breathers -reflex response to nasal obstruction is to open the mouth to maintain an airway -response is not present in most infants until 3 weeks after birth -cyanosis or asphyxia can occur with nasal blockage

Anatomy

-15 to 20 segments (lobes) -Alveoli -Milk-producing cells within lobes -Myoepithelial cells -Contract to send milk to ductules -Size and shape -Hormonal effects Lobes -embedded in fat and connective tissues and well supplied with blood vessels, lymphatic vessels, and nerves -Within each lobe is alveoli (glandular tissue), the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward to the nipple during milk ejection; ducts dilate and expand at milk ejection -Each nipple has multiple pores that transfer milk to the suckling infant - ratio of glandular to adipose tissue in the lactating breast is approximately 2:1 compared with a 1:1 ratio in the nonlactating breast -complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple Size and shape -not accurate indicators of its ability to produce milk -nearly every woman can lactate, a small number have insufficient mammary gland development to breastfeed their infants exclusively -Typically these women experience few breast changes during puberty or early pregnancy -able to produce some breast milk, although the quantity is not likely to be sufficient to meet the nutritional needs of the infant -offer supplemental nutrition to support optimal infant growth Hormonal effects -effects of estrogen, progesterone, human placental lactogen, and other hormones of pregnancy, changes occur in the breasts in preparation for lactation -increase in size due to growth of glandular and adipose tissue -Blood flow to the breasts nearly doubles during pregnancy -Sensitivity of the breasts increases, and veins become more prominent -nipples become more erect, and the areolae darken. Nipples and areolae enlarge -Around week 16 of gestation the alveoli begin producing prepartum milk, or colostrum -Montgomery glands on the areola enlarge -oily substance secreted by these sebaceous glands helps provide protection against the mechanical stress of sucking and invasion by pathogens -odor of the secretions can be a means of communication with the infant

Renal

-An infant should void within 24 hours of life. -98% of infants void within 30 hours of life. -If a newborn has not voided within 48 hours of life it may indicate a renal impairment. -Fluid and electrolyte balance -frequency of voiding varies from 2 to 6 times per day during the first and second days of life -After day 4, approximately 6 to 8 voidings per day of pale straw-colored urine indicate adequate fluid intake -infant who has not voided by 24 hours should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain. Weight Loss -Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake results in a 5% to 10% loss of the birth weight -This usually occurs over the first 3 to 5 days of life -If the mother is breastfeeding and her milk supply has not come in yet (which occurs by the third or fourth day after birth), the neonate is somewhat protected from dehydration by its increased extracellular fluid volume -The neonate should regain the birth weight within 10 to 14 days, depending on the feeding method (breast or bottle). Fluid/Electrolyte -term neonate approximately 75% of body weight consists of total body water -weight loss experienced by most newborns during the first few days after birth is caused primarily by extracellular water loss -** Know how many voids we should have per day. Output is an very accurate indicator of feeding and if baby is getting enough fluids (know the numbers)

Hepatic cont.

-Early-onset jaundice (Pathologic) is usually related to increased bilirubin production -Late-onset jaundice (Physiologic) is most often related to delayed elimination of bilirubin, with or without increased production -Among the factors that increase the risk of hyperbilirubinemia, prematurity is the most significant. Hyperbilirubinemia (Jaundice) -There are 2 different types of jaundice and it is all based on when it appears (so understand the time frames of when it appears) -jaundice is the buildup of unconjugated bilirubin in baby; it starts on the head, and works its way down- the worst it gets, the farther down the body it will go. -will not be asked about the bilirubin levels (do know temp numbers and glucose numbers from up in the notes) Physiologic: -After 24 hours during first week of life (usually 2,3,4 5 days after birth) -occurs in approximately 60% of newborn infants born at term and 80% of preterm infants -appears after 24 hours of age and usually resolves without treatment -Increased RBC volume and decreased lifespan -Reabsorb due to lack of intestinal bacteria and decreased gi motility -Progresses from head down toward trunk and lower extremities -Pathologic (nonphysiologic) -Within 24 hours of life -unconjugated hyperbilirubinemia is either pathologic in origin or severe enough to warrant further evaluation and treatment -Jaundice is usually considered pathologic if it appears within 24 hours after birth, if total serum bilirubin levels increase by more than 6 mg/dl in 24 hours, and if the serum bilirubin level exceeds 15 mg/dl at any time -High levels of unconjugated bilirubin are usually caused by excessive production of bilirubin through hemolysis •Bilirubin levels: Total serum bilirubin can be determined between conjugated and unconjugated and figureo ut how much of each you have •Coombs' test: to determine hemolytic disease -Direct is done on baby -Indirect on mom -*know which one is direct and indirect •Phototherapy: Different types (high energy output in blue-green spectrum) -Photoconverting bilirubin molecules into water-soluble isomer that can be excreted without conjugation -Continuous except during feeding -Need to protect eyes and genitals (diapers) -Can cause: eye damage, loose stools, dehydration, hyperthermia, lethargy, skin rashes **need to turn baby every 2 hours, has to wear a diaper, and have to cover their eyes. -babies can go home on phototherapy if the jaundice is not severe, and education is key for that.

Uniqueness of human milk

-It is a dynamic substance with a composition that changes to meet the changing nutritional and immunologic needs of the growing infant -specific to the needs of each infant; for example, the milk produced by mothers of preterm infants differs in composition from that of mothers who give birth at term. -contains immunologically active components that provide some protection against a broad spectrum of bacterial, viral, and protozoal infections Main immunoglobulin: IgA -IgG, IgM, IgD, and IgE are also present. Lactogenesis -milk composition and volumes vary according to the stage of lactation Stage I -Stage I, beginning at approximately 16 to 18 weeks of pregnancy, the breasts prepare for milk production by producing prepartum milk, or colostrum Stage II Stage II of lactogenesis begins with birth as progesterone levels drop sharply when the placenta is removed -first 2 to 3 days after birth, the baby receives colostrum, a clear, yellowish fluid that is rich in antibodies and higher in protein but lower in fat than mature milk -high protein level of colostrum facilitates binding of bilirubin, and the laxative action of colostrum promotes early passage of meconium -important in establishing normal Lactobacillus bifidus flora in the infant's digestive tract -By 3 to 5 days after birth the woman experiences a noticeable increase in milk production. This is often referred to as the milk coming in. Stage III -Breast milk continues to change in composition for approximately 10 days, when the mature milk is established -have an understand of the stages, don't need to know a lot of details.. Composition changes -composition of human milk changes over time as the infant grows and develops -composition of human milk changes over time as the infant grows and develops -Variations in fat content exist between breasts and among individuals -During each feeding the concentration of fat gradually increases from the lower fat foremilk to the richer hindmilk -hindmilk contains the denser calories from fat necessary for ensuring optimal growth and contentment between feedings -breastfeeding the infant long enough to supply a balanced feeding is important -Milk production gradually increases as the baby grows -Infants have fairly predictable growth spurts (at approximately 10 days, 3 weeks, 6 weeks, 3 months, and 6 months), when more frequent feedings stimulate increased milk production -growth spurts usually last 24 to 48 hours, after which the infants resume their usual feeding pattern as the mother's milk supply increases -remember moms first milk is called colostrum and has lots of good stuff in it; and mom's mature milk comes in in 3-5 days. -every time mom sits down to breastfeed, the first part that comes out is called foremilk and has less fat to it, and that is why you have to feed long enough on the side you are feeding to get to that hind milk with all the fat that helps the baby grow and gain weight)

Skeletal

-Rapid development during 1st year of life -At birth more cartilage present -Head at term is approx ¼ of total body length -Legs are approx 1/3 of total body length -Face can appear small in relation to head -Cranial size and shape can seem distorted due to molding from labor -Make sure you understand the differences in these 3 things. Also know the caput and the cephalhematoma resolve on their own; one takes longer than the other. Educate the parents on not pressing on it, and make sure they are doing gentle handling on the head Caput succedaneum -Edematous area of scalp most common on occiput -Compression of local vessels, slowing venous return causing increase in fluids within scalp causing edema -Disappears spontaneously in 3-4 days Cephalhematoma -Collection of blood between skull bone and periosteum -Does not cross cranial suture line -Firmer and well defined -Resolves in 2-8 weeks Subgaleal hemorrhage -Bleeding into subgaleal compartment-space that connects frontal and occipital muscles and forms inner surface of scalp -Result from traction or shear forces to scalp (vacuum) -Can be severe due to blood loss leading to hypovolemic shock, DIC and death -typically these occur as a result of the birthing process and coming through birth canal and due to the vacuum or forceps, etc. but can get worse after they are born.

Cultural Influences of feeding methods

-Working effectively with these groups requires that nurses are knowledgeable and sensitive to the cultural factors influencing infant feeding practices -In general people who have immigrated to the United States from poorer countries often choose to formula feed their infants because they believe it is a better, more "modern" method or because they want to adapt to U.S. culture and perceive that formula feeding is the custom •Beliefs and practices vary across cultures Hispanic -Hispanic women who are more acculturated may be less likely to breastfeed and, if they do, tend to breastfeed for a shorter duration Las dos cosas: combining breastfeeding and commercial infant formula -based on the belief that by combining the two methods, the mother and infant receive the benefits of breastfeeding, and the infant receives the additional vitamins from infant formula -can result in problems with milk supply and babies refusing to latch on to the breast, which can lead to early termination of breastfeeding Muslim -Muslim culture, breastfeeding for 24 months is customary -Before the first feeding rubbing a small piece of softened date on the newborn's palate is a ritual -Because of the cultural emphasis on privacy and modesty, Muslim women may choose to bottle feed formula or expressed breast milk while in the hospital Southern Asia, Pacific Islands, sub-Saharan Africa -beliefs about the harmful nature or inadequacy of colostrum, some cultures apply restrictions on breastfeeding for a period of days after birth -Before the mother's milk is deemed to be "in," babies are fed prelacteal food such as honey or clarified butter in the belief that these substances will help clear out meconium Western cultures -women are more likely to try to "schedule" feeding sessions Mother's intake of food -Korean mothers often eat seaweed soup and rice to enhance milk production -Hmong women believe that boiled chicken, rice, and hot water are the only appropriate nourishments during the first postpartum month Between energy forces, hot and cold, or yin and yang is integral to the diet of the lactating mother: -Hispanics, Vietnamese, Chinese, East Indians, and Arabs often use this belief in choosing foods. -"Hot" foods are considered best for new mothers -chicken and broccoli are considered "hot," whereas many fresh fruits and vegetables are considered "cold."

Physical Assessment

-detailed, thorough physical examination should follow within 24 hours after birth see Table 24-3 pages 554-564 -important to remember to include the parents in the assessment to help parents to understand wha things you are doing to assess the baby and helps the parents be involved and for them to ask questions. General appearance -maturity level can be gauged by assessing general appearance. Features to assess in the general survey include: -Posture -Activity -any overt signs of anomalies that can cause initial distress -presence of bruising or other birth trauma -state of alertness -normal resting position of the neonate is one of general flexion Vital Signs: Blood pressure is not routinely assessed unless cardiac problems are suspected -irregular, very slow, or very fast heart rate can indicate a need for further evaluation of circulatory status including BP measurement Axillary temperature is a safe, accurate measurement of temperature -artery, tympanic, and oral routes for measuring temperature in the newborn are not considered accurate -normal axillary temperature averages 98.6° F, with a range from 97.7° to 99.5° F Respiratory rate varies with the state of alertness and activity after birth -are abdominal in nature and can be counted by observing or lightly feeling the rise and fall of the abdomen -respirations are shallow and irregular -should be counted for a full minute to obtain an accurate count because there are periods when respirations can cease for seconds (≤20) and resume again -observe for symmetry of chest movement -respiratory rate will vary between 30 and 60 breaths/minute -respiratory rate can exceed 60 breaths/minute if the newborn is very active or crying Apical pulse rate should be obtained on all newborns -should be for a full minute, preferably when the infant is asleep or in a quiet alert state -heart rate ranges from 110 to 160 beats/minute when the infant is awake -common to detect brief irregularities in the heart rate -varies with the newborn's behavioral state -term infant in deep sleep can have a heart rate in the 80s or 90s; the rate should increase when the infant awakens -not unusual for a crying infant to have a heart rate greater than 160; the heart rate should decrease when the crying ceases Measuring physical growth Head circumference/body length -head is measured at the widest part, which is the occipitofrontal diameter -tape measure is placed around the head just above the infant's eyebrows. The term neonate's head circumference ranges from 32 to 36.8 cm (12.6 to 14.5 in -places the newborn on a flat surface and extends the leg until the knee is flat against the surface. -term neonate, head-to-heel length ranges from 45 to 55 cm (17.7 to 21.7 in) Neurological assessment -useful information about the infant's nervous system and state of neurologic maturation

Behavioral Characteristics cont.

-infants possess sensory capabilities that indicate a state of readiness for social interaction Sensory behaviors: Vision -At birth the eye is structurally incomplete, and the muscles are immature -Accommodation is not present but improves over the first 3 months of life -pupils react to light, the blink reflex is stimulated easily, and the corneal reflex is activated by light touch -Term newborns can see objects as far away as 2.5 feet; The clearest visual distance is 8 to 12 inches, which is approximately the distance between the mother's and infant's faces during breastfeeding or cuddling -prefer black and white, possibly because of the greater contrast. Within 2 to 3 months, they can discriminate colors Hearing -Term newborns can hear and differentiate among various sounds -turn toward a sound and attempt to locate the source -neonate recognizes and responds readily to the mother's voice and shows a preference for high-pitched intonation -accustomed to hearing the regular rhythm of the mother's heartbeat, which was a constant sound during intrauterine life -is integral to bonding and attachment and may be more important than vision -Routine hearing screening is recommended for all newborns before hospital discharge Smell -highly developed sense of smell and can detect and discriminate distinct odors -react to strong odors such as alcohol or vinegar by turning their heads away but are attracted to sweet smells -By the fifth day of life newborn infants can recognize their mother's smell -infants are able to smell breast milk and can differentiate their mothers from other lactating women -babies can smell really well Taste -Young infants are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking -newborn can distinguish among tastes and has a preference for sweet solutions Touch -face (especially the mouth), the hands, and the soles of the feet seem to be the most sensitive -Reflexes can be elicited by stroking the infant -responses to touch suggest that this sensory system is well prepared to receive and process tactile messages -Birth trauma or stress and depressant drugs taken by the mother decrease the infant's sensitivity to touch or painful stimuli.

Discharge Planning

-make sure mom feels very comfortable taking care of herself and baby. -may need to do more teaching if 1st baby or have not had a baby for 10 years, etc. •Basic infant care •Signs and symptoms to report: -Increased bleeding, increased pain, s/s of infection (such as fever, chills, drainage, foul smelling odor) and these are all things that mom should call the doctor about -If baby gets lethargic and not feeling well, baby has fever, etc. •Sexual Activity: they need to wait till the 6 week mark ideally. You want the vaginal discharge to stop and the perineum to heal completely before resuming sex. Also remember that breastfeeding causes that vaginal dryness, etc. •Contraception: we have this convo before they go home, whether they are breastfeeding or not. Breastfeeding does help with contraception, however it is very influenced on how much and often they are breastfeeding so you cannot rely on it. It is okay for women to get on contraception, but usually wait until the 6 week check up to get on it. It is better to at least wait for 4-6 weeks to establish a good milk supply bc some hormonal contraceptives can impact the breast milk supply. An IUD is a great option for a breastfeeding mom bc it does not mess with the hormones. For moms who are not breastfeeding, she can use contraceptive pills almost immediately (since they can ovulate after 4 weeks of delivery) •Home Meds: all the meds she is going home on, she needs to know how to take those, and a lot of women continue taking their prenatal vitamins esp. because lots of things are depleted after delivery, and if they are breastfeeding. A lot of women will go home on iron bc she has lost a lot of blood and we want to replete that. They may go home on stool softeners and then pain meds also. •Feeding choices: we want to make sure she is comfortable with her feeding choices whether bottle or breastfeeding •Follow-up appointment: can have this to come back and talk with the lactation nurse after she has gone home to make sure baby is gaining weight well and they are latching well. Both mom (ab 6 weeks out after delivery, but if had a c section, may have an incision check at 2 weeks), and baby needs a follow up appointment (when depends on i breastfeeding or not. breastfeeding babies need to see pediatricians sooner- usually about 48 hrs after discharge bc those babies have more issues with dehydration and eight loss, and jaundice since it takes a couple days for moms milk to come in. Formula fedd babies can usually follow up in about 2 weeks after delivery bc they don't have the potential for complications like the breastfed babies. •Referrals and community support groups: moms may do support groups with moms that are breast feeding. -an important thing we do at discharge is sending the right baby home with the right mom by comparing the wristbands and making sure they match.

Immediate Care after Birth

-nurse places identically numbered bands on the infant's wrist and ankle, on the mother, and on the father or significant other -electronic infant security tag or abduction system alarm should be placed on all newborns to aid in protecting against infant abduction Initial physical assessment: -infant is placed prone skin-to-skin on the mother's abdomen or chest, and the nurse assesses the airway -Slight extension of the neck helps keep the airway patent. -Drying the infant with vigorous rubbing removes moisture to prevent evaporative heat loss and provides tactile stimulation to stimulate respiratory effort -mother and her newborn are covered with a warm blanket and a cap is placed on the infant's head -newborn should be breathing spontaneously; trunk and lips should be pink; acrocyanosis is a normal finding -heart rate: -grasping the base of the cord or by auscultating the left chest with a stethoscope -counts for 6 seconds and multiplies by 10 to calculate the heart rate -should be greater than 100 beats/minute -minimizing interference in the initial parent-infant acquaintance process Apgar scoring -permits a rapid assessment of the newborn's transition to extrauterine life based on five signs that indicate the physiologic state of the neonate (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord (2) respiratory effort, based on observed movement of the chest wall (3) muscle tone, based on degree of flexion and movement of the extremities (4) reflex irritability, based on response to suctioning of the nares or nasopharynx (5) generalized skin color, described as pallid, cyanotic, or pink -Evaluations are made at 1 and 5 minutes after birth and can be completed by the nurse or birth attendant -Scores of 0 to 3 indicate severe distress -scores of 4 to 6 indicate moderate difficulty -scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life -do not predict future neurologic outcome but are useful for describing the newborn's transition to the extrauterine environment and the need for resuscitation -you need to know how to do Apgar. The primary goal is for the baby is to get them to have effective respirations and start breathing.

Cardiovascular

-will not be asked on the cardiac defects on test -Infant's first breaths, combined with increased alveolar capillary distention, and clamping cord inflate the lungs and reduce pulmonary vascular resistance to pulmonary blood flow from the pulmonary arteries -Pulmonary artery pressure drops, and pressure in the right atrium declines -Increased pulmonary blood flow from the left side of the heart increases pressure in the left atrium, which causes a functional closure of the foramen ovale -Ductus arteriosus constricts in response to increased oxygenation- in term infants it functionally closes within the first 24 hours after birth; permanent (anatomic) closure usually occurs within 3 to 4 weeks, and the ductus arteriosus becomes a ligament -Cord clamping and severed functionally closes umbilical arteries, vein, and ductus venosus; convert to ligaments in 2-3 months. •Heart rate and sounds -term newborn ranges from 110 to 160 -brief fluctuations greater and less than these values usually noted during sleeping and waking states -Immediately after birth the heart rate can be palpated by grasping the base of the umbilical cord. -Irregular in first few hours is common Apical impulse (point of maximal impulse [PMI]) -fourth intercostal space and to the left of the midclavicular line = also known as the precordial activity -should be determined for all infants -Auscultation should be for a full minute, preferably when the infant is asleep •Blood pressure -vary with gestational age, weight, state of alertness, and cuff size -MAP should be equivalent to the weeks of gestation -BP increases by the second day of life, with minor variations noted during the first month of life •Blood volume -term newborn averages 80-100 ml/kg of body weight -Delayed clamping expands the blood volume from the so-called placental transfusion of blood to the newborn. Delayed cord clamping (≥2 minutes after birth) has been reported to be beneficial in improving hematocrit and iron status and decreasing anemia and NEC; such benefits can last up to 6 months •Signs of risk for cardiovascular problems Persistent tachycardia: -more than 160 beats/minute -can be associated with anemia, hypovolemia, hyperthermia, or sepsis Persistent bradycardia: -less than 100 beats/minute -can be a sign of a congenital heart block or hypoxemia. Skin color: -Pallor in the immediate postbirth period is often a sign of underlying problems such as anemia or marked peripheral vasoconstriction as a result of intrapartum asphyxia or sepsis -prolonged cyanosis other than in the hands or feet can indicate respiratory and/or cardiac problems -presence of jaundice can indicate ABO or Rh factor incompatibility problems

Recommended Infant Nutrition

AAP recommends: -Exclusive breastfeeding - first 6 months -Continued breastfeeding - at least 12 months -Appropriate complementary solid foods are added to the diet in second 6 months -Breastfeeding rates (CDC, 2016) -Breastfeeding should continue for 1 year and thereafter as desired by the mother and her infant -According to the World Health Organization infants should be exclusively breastfed for 6 months, receive safe and nutritionally adequate complementary foods beginning at 6 months, and continue breastfeeding until age 2 or beyond. -increase in breastfeeding rates may be related to the increase in the percentage of facilities with at least 90% of mothers and newborns having skin-to-skin contact after birth and in the percentage of facilities with at least 90% of mothers and newborns rooming-in -lowest breastfeeding rates are among non-Hispanic black women -minority group most likely to breastfeed is Hispanic women

Gestational Age Assessment: classification by birth weight

Classification by birth weight: -AGA -LGA -SGA -provides a more satisfactory method for predicting mortality risks and providing guidelines for management of the neonate than estimating gestational age or birth weight alone - birth weight, length, and head circumference are plotted on standardized graphs that identify normal values for gestational age -appropriate for gestational age (AGA): (between the 10th and 90th percentiles) can be presumed to have grown at a normal rate regardless of the length of gestation—preterm, term, or postterm -Large for gestational age (LGA): (more than the 90th percentile) can be presumed to have grown at an accelerated rate during fetal life -small for gestational age (SGA): infant (less than the 10th percentile) can be presumed to have grown at a restricted rate during intrauterine life -birth weight influences mortality. So, the higher birth weight has a decreased morbidity and mortality and lower the weight, the higher the mortality rate. -know what the babies percentiles and what they would be categorized under. Weight conversion: 6lb 4oz and convert to grams. 6/2.2= 2.727. 4/16lb= 0.25. 0.25/2.2= 0.114 2.727 + 0.114= 2.841 kg =28.41 g if given 2835 g and need to convert to lb and oz. 2.835 kg x 2.2 lb= 6.237 lb so 6lb and .237x 16= 3.7 oz rounded to =6lb 4 oz so basically just know 1 kg= 2.2 lb and that 16 oz are in a lb.

Gestational Age Assessment: classification by gestational age

Classification by gestational age: -Late Preterm: 34 0/7 through 36 6/7; have been called "the great impostors" because they are often the size and weight of term infants and are often treated as healthy newborns - increased risk for respiratory distress, temperature instability, hypoglycemia, apnea, feeding difficulties, and hyperbilirubinemia -Preterm: prior to 37 0/7 -Early Term: 37 0/7 through 38 6/7 -recent increase in the number of early term infants is associated with elective inductions and elective cesarean births that are scheduled before 39 weeks -early term infants are at greater risk for short- and long-term health problems -higher risk of hypoglycemia, respiratory problems such as respiratory distress syndrome and transient tachypnea of the newborn (TTNB), and a greater likelihood of NICU admission -increased risk for long-term problems such as learning difficulties (e.g., attention deficit hyperactivity disorder [ADHD]) -higher neonatal, postnatal, and infant mortality rates -Full Term: 39 0/7 through 40 6/7 -Late Term: 41 0/7 through 41 6/7 -Postterm: 42 0/7 and beyond -Postmature: 42 6/7 and showing signs of placental insufficiency Postterm or Postmature: -Some infants are appropriate for gestational age, but show the characteristics of progressive placental dysfunction Labeled as postmature and are likely to: -have little if any vernix caseosa (remains in the skinfolds may be stained deep yellow or green, which is usually an indication of meconium in the amniotic fluid) -absence of lanugo -abundant scalp hair -long fingernails -skin is often cracked, parchment-like, and desquamating -physical appearance that reflects intrauterine deprivation -Depletion of subcutaneous fat gives them a thin, elongated appearance -significant increase in fetal and neonatal mortality in postmature infants compared with those born at term -prone to fetal distress associated with the decreasing efficiency of the placenta, macrosomia, and meconium aspiration syndrome -greatest risk occurs during the stresses of labor and birth, particularly in infants of primigravidas, or women giving birth to their first child -know the signs of a postmature infant is.

Emotional/Psychosocial Needs

Cultural practices -Cultural Considerations Box on p. 436 for examples -Influence behaviors of woman and family during postpartum period -Conduct a cultural assessment to identify preferences -Don't make assumptions based on ethnicity -Encourage cultural beliefs and behaviors as long as no ill effects -remember the child bearing process is a big time where we see different culture preferences, and the best way to do this for them is to ask what they would like. -For some cultures, PP period is considered a very vulnerable time for the mom and the family puts lots of activity restrictions on mom and do not want her doing anything but rest. -In chinese cultures, they only want warm stuff to restore the "cold" they had so don't be surprised if they refuse ice water or ice packs.

Immune

Immune system: -make sure you know how to get these, whether passive or active immunity -remember babies don't fight infection well -one of the leading causes of morbidity and mortality -one fo the greatest risk factors is prematurity since their organs are immature. -passive immunity is what you get from mom. IgG •Location: Blood, ECF (extracellular fluid) •Passive Immunity -At birth most of the circulating antibodies in the newborn are immunoglobulin G (IgG) antibodies that were transported across the placenta from the maternal circulation -IgG is key to immunity to bacteria and viruses -passive immunity afforded the infant through the placental transfer of IgG usually provides sufficient antimicrobial protection during the first 3 months of life -Production of adult concentrations of IgG is reached by 4 to 6 years of age •IgM •Location: Blood •8th week of gestation -The fetus is capable of producing IgM by the eighth week of gestation, and low levels are present at term - IgM is important for immunity to blood-borne infections and is the major immunoglobulin synthesized during the first month -baby starts producing this on their own, so technically active immunity. •IgA •Location: Breastmilk •Passive Immunity -IgA is missing from the respiratory and urinary tracts, and, unless the newborn is breastfed, it also is absent from the GI tract -secretory IgA in human milk acts locally in the intestines to neutralize bacterial and viral pathogens. It can also lessen the risk of allergy and food intolerance through modulation of exposure to foreign milk protein antigens Risk of Infection -All newborns, and preterm newborns especially, are at high risk for infection during the first several months of life -Temperature instability or hypothermia can be symptomatic of serious infection -newborns do not typically exhibit fever, although hyperthermia can occur (temperature greater than 100.4° F] -Lethargy, irritability, poor feeding, vomiting or diarrhea, decreased reflexes, and pale or mottled skin color are some of the clinical signs that suggest infection -Respiratory symptoms such as apnea, tachypnea, grunting, or retracting can be associated with infection such as pneumonia -Risk factors include premature rupture of membranes, chorioamnionitis, maternal fever, antenatal or intrapartal asphyxia, invasive procedures, stress, and congenital anomalies

Integumentary

Integumentary system: Vernix caseosa -After 35 weeks of gestation the skin is covered by vernix caseosa (a cheeselike, whitish substance) that is fused with the epidermis and serves as a protective covering: -a complex substance that contains sebaceous gland secretions -has emollient and antimicrobial properties and prevents fluid loss through the skin; it also has antioxidant properties -Removal of the vernix is followed by desquamation of the epidermis in most infants -evidence that leaving residual vernix intact after birth has positive benefits for neonatal skin such as decreasing the skin pH, decreasing skin erythema, and improving skin hydration. Sweat glands; milia =Distended, small, white sebaceous glands noticeable on the newborn face are known as milia -day 3 sweating begins on the face, then progresses to the palms Desquamation -(peeling) of the skin of the term infant does not occur until a few days after birth -Large generalized areas of skin desquamation present at birth can be an indication of postmaturity. Mongolian spots -bluish black areas of pigmentation, can appear over any part of the exterior surface of the body, including the extremities -These normal skin pigmentations can be mistaken for bruises once the infant is discharged, which can raise suspicion of physical abuse Nevi: nevus flammeus and nevus vascularis Nevus simplex: -also known as salmon patches, telangiectatic nevi, "stork bites," or "angel kisses," are the result of a superficial capillary defect -usually small, flat, and pink and are easily blanched -most common sites are the upper eyelids, nose, upper lip, and nape of the neck -port-wine stain, or nevus flammeus, is usually visible at birth and is due to an asymmetric postcapillary venule malformation -nevus vascularis, or strawberry hemangioma, is a common type of capillary hemangioma that occurs more often in female infants -typical lesion is a raised, sharply demarcated, bright or dark red rough-surfaced swelling, usually appearing on the head -more than half of affected infants, lesions are present at birth; the remainder appear during the early weeks after birth. Most lesions reach maximum growth in 6 to 8 months, although deeper hemangiomas can continue to grow for up to 2 years Erythema toxicum -a transient rash, is also called erythema neonatorum, newborn rash, or flea bite dermatitis - appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks of age -thought to be an inflammatory response -rash has no clinical significance and requires no treatment

Signs of Respiratory Distress

Nasal Flaring -can see the nostrils flaring when infant is breathing Retractions -Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper airway obstruction -Seesaw or paradoxical respirations (exaggerated rise in abdomen with respiration as the chest falls) instead of abdominal respirations are abnormal and should be reported Grunting -Gutteral rumble upon expiration Analgesics or Anesthetics -respiratory rate of the infant can be slowed, depressed, or absent Apneic episodes -can be related to several events (rapid increase in body temperature, hypothermia, hypoglycemia, or sepsis) that require thorough evaluation -Tachypnea can result from inadequate clearance of lung fluid, or it can be an indication of newborn respiratory distress syndrome -Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses Acrocyanosis -bluish discoloration of hands and feet, is a normal finding in the first 24 hours after birth -Transient periods of duskiness while crying are common immediately after birth; however, central cyanosis is abnormal and signifies hypoxemia -Central cyanosis: can be the result of inadequate delivery of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. (you would see central cyanosis on the babies lips and in their chest area) -Report a RR of <30 or >60 -Acrocyanosis: normal finding in the first 24 hours after birth

Gestational Age Assessment: New Ballard Score

New ballard score -assesses six external physical and six neuromuscular signs -Cumulative score correlates with gestational age -GA < 26 weeks should be done within 12 hours of birth -GA > 26 weeks should be done within 96 hours of birth -When gestational age is determined according to the New Ballard Score, the newborn will fall into one of the following nine possible categories for birth weight and gestational age: -AGA—term, preterm, postterm; -SGA—term, preterm, postterm; or -LGA—term, preterm, postterm -we do not need to know how to do this ballard score. This is something that would be done to help us determine what gestational age the baby is if mom has not had much prenatal care, or if mom has but something is off with assessment stuff to get a good idea of baby. -9 categories, but just know the AGA, SGA, LGA. (the 3 big ones)

Physiologic Problems cont.

Physiological problems: Hypoglycemia -blood glucose < 45 mg/dl (40-60 actually) -blood glucose concentration less than adequate to support neurologic, organ, and tissue function -no consensus about when to screen for hypoglycemia or the level at which treatment should be instituted -Because of variations in devices and operator techniques, it is recommended that any level less than 40 mg/dl should be followed up with a serum glucose level -no need to routinely assess glucose levels of healthy term infants -Adequate feeding helps these neonates maintain normal glucose levels -should be measured in neonates at 34 weeks of gestation or more if risk factors or clinical manifestations of hypoglycemia are present -know who is at risk for hypoglycemia At risk for hypoglycemia include those who are SGA or LGA, infants of mothers with diabetes, and late preterm infants: -All at-risk infants should be fed within the first hour, with glucose testing done 30 minutes after feeding -first 24 hours after birth, late preterm and SGA neonates should be fed every 2 to 3 hours, with glucose levels measured before each feeding -LGA infants and infants of mothers with diabetes should have glucose screening before feedings for at least the first 12 hours after birth -Glucose testing should be done on any infant with clinical signs of hypoglycemia -transient or recurrent and include jitteriness, lethargy, poor feeding, abnormal cry, hypotonia, temperature instability (hypothermia), respiratory distress, apnea, and seizures Hypocalcemia -Serum calcium < 7.8 to 8 mg/dl in term infants and slightly lower (7 mg/dl) in preterm infants -common in critically ill neonates but also can occur in infants of mothers with diabetes or in those who had perinatal asphyxia or trauma and in low-birth-weight and preterm infants -Infants born to mothers treated with anticonvulsants during pregnancy also are at risk -Early-onset hypocalcemia usually occurs within the first 24 to 48 hours after birth -Signs of hypocalcemia include: jitteriness, high-pitched cry, irritability, apnea, intermittent cyanosis, abdominal distention, and laryngospasm, although some hypocalcemic infants are asymptomatic -self-limiting and resolves within 1 to 3 days. -Treatment usually includes early feeding of an appropriate source of calcium such as fortified human milk or preterm infant formula -hypoglycemia and hypocalcemia looks similar but with hypocalcemia, they have the high-pitched cry and that is what can tell the difference.

Lactogenesis

Prolactin -Prolactin prepares the breast to secrete milk. -During pregnancy prolactin prepares the breasts to secrete milk and during lactation to synthesize and secrete milk -After the mother gives birth a precipitous fall in progesterone triggers the release of prolactin from the anterior pituitary gland -Prolactin levels are highest during the first 10 days after birth, gradually declining over time but remaining above baseline levels for the duration of lactation -Prolactin is produced in response to infant suckling and emptying of the breasts Supply-meets-demand system -Milk production is a supply-meets-demand system (i.e., as milk is removed from the breast, more is produced). -Incomplete removal of milk from the breasts can lead to decreased milk supply Oxytocin -Oxytocin is essential to lactation - As the nipple is stimulated by the suckling infant, the posterior pituitary is prompted by the hypothalamus to produce oxytocin -Responsible for the milk ejection reflex (MER), or let-down reflex -MER is triggered multiple times during a feeding session -Thoughts, sights, sounds, or odors that the mother associates with her baby (or other babies) such as hearing the baby cry can trigger the MER -Report a tingling "pins and needles" sensation in the breasts as milk ejection occurs, although some mothers can detect milk ejection only by observing the sucking and swallowing of the infant -Can occur during sexual activity because oxytocin is released during orgasm -Can be inhibited by fear, stress, and alcohol consumption MER can be triggered during labor, as evidenced by leakage of colostrum -readies the breasts for immediate feeding by the infant after birth -mothers who breastfeed are at decreased risk for postpartum hemorrhage -Uterine contractions that occur with breastfeeding are often painful during and after feeding for the first 3 to 5 days -more common in multiparas and tend to resolve completely within 1 week after birth Nipple-erection reflex -nipple-erection reflex is an important part of lactation -When the infant cries, suckles, or rubs against the breast, the nipple becomes erect, which aids in the propulsion of milk through the ducts to the nipple pores -Some women have flat or inverted nipples that do not become erect with stimulation; these women likely need assistance with effective latch; Their infants should not be offered bottles or pacifiers until breastfeeding is well established

Perineal Repair: Before/After

REEDA—Perineum Assessment -We are assessing it just like any other incision site •R = Redness •E = Edema or swelling (don't want to see this bc would be a sign of infection) •E = Ecchymosis or bruising •D = Drainage (we don't want to see any drainage) •A = Approximation of episiotomy or laceration (that they are lining up next to eachother; we want to see a nice clean line) Perineal Care •Care of an episiotomy/ laceration (having one of these still increases the risk for infection bc there is a break in skin integrity) -Assess -Cleansing (we need to keep this clean and have proper hygiene to prevent infection. Practicing good hand hygiene every time they go to the bathroom will help protect the site, wiping front to back to prevent Ecoli from getting to the site, frequent pad changes, at a minimum 4x/day which is x6 hrs. It is okay to use a mild soap on the stitches and to pat it dry. -Ice Pack (esp. in the first 24 hours when the swelling is at its worst and this will help decrease the swelling) -Squeeze Bottle (or peri bottle helps facilitate it to keep the site clean. You will put warm water on it and squeeze the whole bottle on the perineum and this also feels good and is a comfort measure) -Sitz bath (a basin that sits over the toilet bowl. You fill the bag up with warm or cool water and have the mom sit in it running over their perineum.) -Topical Applications: Both of these help to numb the site and is very comforting and moms love it -Anesthetic creams or sprays (Dermaplast)- this is a spray that you spray on their bottom. -Witch hazel pads (Tucks)- this has a cooling burning kind of feeling that numbs and helps not only with the repair site, but they are also very comforting for hemorrhoids.

Birth Injuries

Retinal and subconjunctival hemorrhages -result from rupture of capillaries caused by increased pressure during birth -usually clear within 5 days and present no further problems -Parents need explanation and reassurance that these injuries are harmless. Soft-tissue injuries: erythema, ecchymoses, petechiae -Localized discoloration can appear over the presenting part as a result of forceps- or vacuum-assisted birth -Ecchymoses and edema can appear anywhere on the body -Petechiae (pinpoint hemorrhagic areas) acquired during birth can extend over the upper trunk and face -benign if they disappear within 2 or 3 days of birth and no new lesions appear -Ecchymoses and petechiae can be signs of a more serious disorder, such as thrombocytopenic purpura Trauma secondary to dystocia -Trauma to the presenting fetal part can occur during labor and birth -Forceps injury and bruising from the vacuum cup occur at the site of application of the instruments -forceps injury commonly produces a linear mark across both sides of the face in the shape of forceps blades -affected areas are kept clean to minimize the risk for infection. -resolve spontaneously within several days with no specific therapy -Bruises over the face can be the result of face presentation -breech presentation, bruising and swelling may be seen over the buttocks or genitalia -skin over the entire head can be ecchymotic and covered with petechiae caused by a tight nuchal cord -If the hemorrhagic areas do not disappear spontaneously in 2 days or if the infant's condition changes, the primary health care provider is notified Accidental lacerations -can be inflicted with a scalpel during a cesarean birth -can occur on any part of the body but are most often found on the scalp, buttocks, and thighs -usually superficial and need only to be kept clean -a lot of the injuries you see at birth, most are minor but there are a few that could be fatal. These injuries occur to the delivery and labor and birth to the baby, nothing that happened afterwards. -on the babies skin, blanch the area, and then when you take the finger off, it is white and goes back to normal. To figure out if there is a hemorrhagic area and bruising, it will not blanch. But, a rash or just a skin pigmentation difference, those will blanch. -For jaundice, you can do that same thing, but you will see yellow before the blood comes back in. You can do it over bony areas or whatever (forehead or nose is good)

Behavioral Characteristics

Sleep-Wake States Early newborn period -Alternate period of sleep and wake resembling fetal pattern -Six states: -Deep sleep and light sleep -Drowsy, quite alert, active alert, and crying -Optimal state is quiet alert when you can see smiling, vocalizing, move with speech, watch faces and respond to stimuli -State modulation is ability to make smooth transitions between states -Ability to regulate is important to neurobehavioral development Purposeful behavior: Used to maintain optimal arousal state: -Actively withdraw by increasing physical distance -Reject by pushing away with hands and feet -Decrease sensitivity by falling asleep or breaking eye contact by turning head -Using signaling behaviors such as fussing or crying 1st 6 weeks -Steady decrease in active REM sleep to total sleep -Steady increase in quite sleep to total sleep -Periods of wakefulness increase -Sleep approx 16-19 hours/day Other factors influencing newborn behavior: Gestational age -CNS immaturity is reflected in reflex development, sleep-wake states, and ability (or lack thereof) to regulate or modulate a smooth transition between different states -preterm neonate with an immature CNS the entire body responds to a pinprick of the foot, although the response may not be observed by an untrained observer -more mature infant withdraws only the foot Time -time elapsed since birth affects the behavior of infants as they attempt to become organized initially -Time elapsed since the previous feeding and time of day also can influence infants' responses Stimuli -newborn responds to animate and inanimate stimuli -intensive care nurseries observe that infants respond to loud noises, bright lights, monitor alarms, and tension in the unit -If a mother is tense, nervous, or uncomfortable while feeding her infant, the infant may sense her tension and demonstrate difficulty feeding. Medication -No conclusive evidence exists regarding the effects of maternal analgesia or anesthesia during labor on neonatal behavior -Researchers who have studied the effects of epidural medications on breastfeeding behaviors have been unable to show a cause-and-effect relationship -these are normal

Postpartum Blues

•Also knows as the "baby blues": a phenomenon that affects a lot of women after birth •Experienced by 50-80% of women •Transient, short-lived period of mild depression (occurs for no longer than 2-3 weeks after birth) -moms are jus often overwhelmed with this responsibility of having a new baby, or if they have kids at home and having a hard time, etc. •Clinical manifestations: emotionally labile (moody), crying for no apparent reason, difficulty sleeping, feeling of letdown, anxiety, sadness (but mom is still able to function and take care off themselves and baby which is important bc it is what separates it from true PP depression) Coping with Postpartum Blues (and help it stop quicker) •Patient Education -The blues are NORMAL (and actually really common so important to teach them that) -Rest!- a good tip to encourage mom to nap when baby is napping -Relaxation techniques -Encourage the mother to take time for herself (letting other people come over to help you out) -Spend time out of the house (go for a walk, etc. or go to lunch with your friends) -Express your feelings (it is good to talk about it, and when they don't do that thats when it can kind of get out of control) -Seek support -Symptoms to report: when this progresses to the point where mom is having very extreme sadness and depression and mom can no longer take care of herself or baby, then we know it is progressing and getting worse than just the normal postpartum blues.

Benefits of Breastfeeding

•Benefits of breastfeeding Benefits for Infant: Reduced risk for: -Nonspecific gastrointestinal infections -Celiac disease -Childhood inflammatory bowel disease -Necrotizing enterocolitis in preterm infants -Clinical asthma, atopic dermatitis, and eczema -Lower respiratory tract infection -Otitis media -SIDS -Obesity in adolescence and adulthood -Types 1 and 2 diabetes -Acute lymphocytic and myeloid leukemia •Benefits for Mother -decreased postpartum bleeding and more rapid uterine involution Reduced risk for: •Ovarian cancer and breast cancer (primarily premenopausal) •Type 2 diabetes •Hypertension, hypercholesterolemia, and cardiovascular disease •Rheumatoid arthritis -Unique bonding experience -sense of empowerment in ability to provide nutrition to infant -Convenience: read to feed and proper temp -Increased maternal role attainment Benefits for families/society -Convenient; ready to feed -No bottles or other necessary equipment -Less expensive than infant formula -Reduced annual health care costs -Less parental absence from work because of ill infant -Reduced environmental burden related to disposal of formula packaging and equipment

Complications of the PP Period:: Hemorrhagic (Hypovolemic) Shock

•Can result from postpartum hemorrhage •Widespread systemic vasoconstriction •Perfusion of body organ becomes severely compromised -Our body has lost so much blood, we will have a systemic vasoconstriction as our body tries to maintain BP and try to keep perfusing the vital organs. And when you have that, it makes organs not being perfused well. •Symptoms: -Weak, rapid pulse -Rapid/ shallow RR -Cool, pale, clammy skin due to the massive vasoconstriction and we don't have blood flow getting to the skin -Decreasing urine output: great indictor of organ perfusion and hydration status; gives us an idea she has lost a lot of blood (we want to see a bare minimum of 30mL/hour) -Hypotension (late sign) -Altered mental status and LOC (as mom is really getting bad) -Accumulation of lactic acid/Acidosis (decreased pH)- due to the organs not being perfused well. Management of Hypovolemic Shock •Goal: replace blood volume and treat the cause of hemorrhage -Call for help! (do not leave her unattended) -Secure IV access (hopefully she already has one, and we may even need 2 which would be ideal, and preferably a large bore like an 18 gauge) -Fluid resuscitation with IVFs and transfusing PRBCs -Administer oxygen by non-rebreather mask -Obtain labs: H&H, platelets, clotting factors -Continue to assess mom: -Pulse, respirations, BP, pulse oximetry, skin, UOP, LOC, mental status If worsening, pulse would be going up, RR would be increasing shallow, BP would keep dropping, Pulse ox would decrease, skin will keep getting more pale, colorless, clammy, LOC would get worse and more drowsy and not. as with us, mental status: she would be getting more confused, anxious.

Comfort and Pain Control

•Common complaints: after cramping, breasts, hemorrhoids, perineum •Non pharmacological methods: for uterine contractions or cramping, you can use a disposable heating pad and you can definitely use one when breastfeeding bc we know that it makes thee cramping worse. -For their bottom no matter for their repair or hemorrhoids, we can use ice packs(ideal for the first 24 hrs when the swelling is the worst), the dermoplast or witch hazel, the spray bottle, sitz bath -If they have sore nipples for breast feeding, the first thing we need to do is assess if the baby is latching correctly since it should not hurt. There are also creams to help protect and provide comfort for the nipples. -For engorgement, the comfort measures depend on whether or not they are breastfeeding. •Pharmacological methods: can give NSAIDs and tylenol for the engorgement. -generally for the discomfort associated with a vaginal delivery, moms take NSAIDs (like motrin, ibuprofin to decrease the inflammation and swelling and most women who deliver vaginally, that is all they need. -For a c section mom, we will also give NSAIDs and usually start out with tordol and then eventually give Motrin, but will also give an opioid analgesic such as Percocet since they have had this big surgery and incision. -Percocet and motrin are perfectly safe for breastfeeding. If either of these meds are not helping with the pain, we prob need to let the doctor know for a c section or if motrin is not helping the vaginal delivery, something else could be going on.

Venous ThromboembolicDisorders (VTE)

•Deep vein thrombosis (DVT) -patients with a c section are even more at risk for this due to their immobileness and that is why all of them get SCD's put on them. -Symptoms: unilateral swelling, redness, tenderness, warm -Treatment: anticoagulants (IV heparin drip) until the legs start looking better (usually about 3-5 days), bed rest with leg elevated, analgesia (comfort care bc it is very painful) -once they have gotten better, they may be put on oral warfarin or lovenox sub q after that. And when they go home, they would be on anticoagulants anywhere from 3-6 months after that. •Pulmonary embolism (PE) -Symptoms: SOB, tachypnea, cough, sometimes syncope if it is bigger, chest pain, tachycardia -Treatment: IV anticoagulation (heparin drip) until symptoms decreased, PO/ SQ anticoagulation for up to 6 months (then PO or sub q to go home one) Nursing Interventions with Thromboembolic Disease •Assessment: continue to monitor leg size, peripheral pulses (to make sure the lower extremity is being perfused), monitor for signs of PE, signs of bleeding (since they will be on anticoagulant therapy so bleeding gums, blood in urine, etc.), pain (make sure we are keeping them comfortable) •Labs: monitor PT- if on coumadin / aPTT- if on heparin while on anticoagulation. •Patient education -Assistance while on bed rest -Breastfeeding (it is okay to breastfeed on heparin, coumadin, and lovenox. If mom is going to be on it for several months, it may be necessary to get the infants clotting levels checked every month or so) -Don't rub the affected area (DVT)- bc we can dislodge the clot and she can have a stroke or PE. -Discharge teaching: make sure she understands how to take the meds, how to give a sub q and rotating sites, understanding the labs she will need to get. Reliable contraception is really important while taking Coumadin bc it has known teratogenic effects (but she will not need to be on any method with estrogen and she will never be able to be on that for the rest of her life if she has had a blood clot)

Nursing Care

•Discharge teaching: Teaching will continue until they walk out of the door. We will provide more if it is her first pregnancy, or maybe it is her first boy and she does know how to care for a circumcision, etc. So we assess and tailor our education for the mom. •Discharge timing ▫Vaginal Birth: ~48 hours ▫C-section: ~72 hours -If there are complications, they will need to stay longer, or if there was a very uncomplicated birth, the doctor may discharge mom and baby within 24 to 36 hours. -We mainly keep this time to make sure mom and baby are stable, and make sure that there are no complications. And the more time we have with them it gives us the opportunity to pick up on more cues to pick up on if there is problems bonding with baby and moms reaction, family dynamics, etc. •Couplet care: mom and baby in room together (we do not see many well baby nurseries anymore) ▫Infant security (bc babies used to be abducted in hospitals; most infants have an alarm on them, either their ankle or umbilical cord) -We try not to take babies out of the room, but if we do the baby needs to stay in the bassinet to take it wherever you need to, and we need to compare arm bands for mom and baby when we take baby out of the room and do it again when we bring baby back to the moms room. •Physical Exam: we do a very focused exam x4 hrs focusing on the breast, uterus and fundus, the bleeding, bladder, and bowel situation.) Although we will be doing a thorough head to toe x1 shift. •Labs ▫Hgb/Hct: will get this usually the morning after delivery. If there has been significant bleeding during delivery, they will get one sooner than waiting until the next morning. ▫Urinalysis (UA): you may or may not be done and will be done via catheter or a clean catch. ▫Urine culture ▫Rubella: It was checked if mom had prenatal care, but if the mom was a rubella non immune, she will get the MMR vaccine to her after birth. ▫Rh status: we are assessing this bc of the potential to give Rhogam.

Forms of Parent-Infant Contact

•Early contact: facilitates the attachment and bonding process (this is going to start that process. This is skin to skin immediately after baby comes out) Skin to skin: -Promotes early and effective breastfeeding -Increases duration of breastfeeding (moms will breastfeed for longer and establish a good milk production bc it actually increases moms prolactin levels) -Associated with improved temperature, blood glucose, and cardiorespiratory stability for baby -some times this can not happen and the baby may need to go straight to NICU, but mom will still have opportunities to bond with the baby even if she misses this initial time. Extended Contact: -Rooming in -> a focus of FAMILY CENTERED CARE; this allows mom and babies dad or family member to be as involved in the care of the baby as possible. Baby may never have to leave the room from mom bc labs, hearing test, etc. can all be done in the room. -Encourage significant other to be involved in the infant's care -Most essential for parents who are at risk for parenting inadequacies (adolescents, low income patients) -part of our assessment is assessing the attachment and bonding behaviors of mom and baby, and we need to recognize this and social work may need to be called in

Breasts

•Engorgement: check for tenderness, firmness, warmth, enlargement •Check nipples: esp. in the breastfeeding moms. Usually if there are nipple problems, it is related to a bad latch and can cause nipples to bled, crack, or develop ulcers on the nipple (we want the skin on the nipples to be intact). Breastfeeding should not be painful, however it can feel a little uncomfortable at first. -for women who are breastfeeding, after they get engorged, they will just be getting relieved each time they feed. BF or NON BF moms: this is "normal": •Day 1-2: soft (won't even feel much different) •Day 2-3: filling (they may start to feel a little discomfort) •Day 3-5: full, soften with breastfeeding BF Mom comfort measures: •Heat: this is comforting and also increases the circulation to the breast and will help with milk production •Supportive bra (breast pads) •Breastfeed or pump: continuing to do this on a regular schedule (x 2-3 hours) to keep the breast empty to help the discomfort. •No soap on nipples: bc it can be drying to the skin and making it more prone to cracking, bleeding, etc. •Provide support while in the hospital and suggest support groups for after discharge (there will b lactation that rounds on all of the moms in the hospital). Breastfeeding can be a learning curve, esp. if a first time mom Non-BF Mom: •First 72 hours: Supportive bra (or a tighter sports bra, or binding up with an ACE bandage) •Avoid: ▫Expressing milk (the biggest thing is we do not want to stimulate the breasts- no matter how tempting and uncomfortable they are) ▫Stimulation ▫Heat (since heat is stimulating and increases circulation) •Treating engorgement: ▫Ice packs ▫Cabbage leaves ▫Analgesics (tylenol and motrin to help relieve the discomfort)

Importance of Rest

•Promoting Rest -Measures to improve rest and promote sleep (labor is a lot for moms so we need to make sure that mom gets rest, and covid has helped mom rest more bc no one is really allowed in the room. A lot of hospitals have quiet time where no visitors are allowed, and nurses should also be staying out off the room during those 2 hours, etc. -We can cluster care and do as much as we can at one time so we can leave and give her uninterrupted rest time. So we may need to coordinate with lab or techs and all go in together to get all our work done at one time. We encourage mom to nap while baby is napping.

Nursing Role

•Provide family centered care- it used to be where all of the family was with the patient and we took care of the whole family, but different now bc of covid •Rest and recovery from labor and birth- we want to. facilitate this bc mom has been through a lot. We can advocate for her and put no visitors on the door to help her rest. •Assessment following birth: of both mom and baby, assessing for normal findings and hopefully identifying abnormal problems pretty quickly to hopefully intervene really quick. Most moms are transferred about 2 hours after birth to the postpartum floor. •Prevention of complications •EDUCATION!!!!- this is a huge role, teaching mom how to take care of herself, warning signs of complications, when to call the doctor, how to take care of baby, circumcision care, umbilical cord care, what to expect after pregnancy, etc.

Ambulation and Activity

•Importance of early ambulation (prevents multiple complications but need to be careful getting patients up, esp. after anesthesia) -After anesthesia -Orthostatic hypotension (due to all of the fluid shifting, and if they have been anesthetized with a epidural or spinal, they are at risk for falls if we get hr up too soon. We also need to think about how much blood mom has lost, and consider how long the epidural or spinal has been out, etc. before we get her up. -We are most worried about the sensorimotor function before we get her up, so we want to test her first, so try tot ask her to lift her hips off the bed and that means she is prob ready to get out of the bed if she does that easily. -Also, when we get her up the first time, we need to consider the orthostatic hypotension so dangle feet on the side of the bed, stand by the side of the bed for a little bit, and definitely call for assistance the first couple of times when they get up. •Activity -Gradually increase (over the 4-6 weeks postpartum, we want them to gradually increase their activity, bc for some patients if they are trying to over do it and exercise too soon, the bleeding can start to increase again) -we want her to do Kegel exercises to try to restore the tone again to prevent future problems -What to avoid: heavy lifting for the PP period, (good rule of thumb is anything heavier than baby, do not lift) bc we don't want to risk ripping her stitches, do not do too much exercises or going up and down the stairs) -Work: most women can be cleared to go back to work by 6 weeks, but most don't go back for 12 weeks. But, there is a law where jobs are required to hold her position for 12 weeks until she comes back.

Assessing Attachment

•Included in postpartum assessment •Rooming in and open visitation -not only does this allow for opportunities for mom to take care of baby but allows us to observe and watch mom so we can pick up on how mom is caring for baby -with open visitation, we can really pick up on the family dynamics and allows us to make observations •Parental behaviors: These are all evidence of good things: -Reaching out for the baby or calling the baby by name -Speaking kindly and positively about the baby -Holding the baby -Talking to the baby -Consoling the baby when it is upset -Asking questions/ desire to learn about the care of newborn -when they are not doing these things, that is when we notice something is not normal and may be a case where social workers need to get involved. -there are certain circumstances: unwanted and unplanned pregnancy, could be a result from sexual abuse or rape, may be in the process of divorcing, or being a single mom and she has to raise the baby on its on. Sometimes there are things about the birth experience too such as a long, hard labor, or if baby is sick and had to go to the NICU, or if baby has a birth defect can all interfere with the inability to bond with the baby. Or things as simple with not wanting the gender of the baby, or the baby is just really fussy and no matter what mom does, she can't calm the baby. Nursing Interventions Promoting Parent-Infant bonding: -Offer opportunity for parents to see and hold the infant immediately after birth -Have parents participate in newborn care -Permit rooming in of both infant and significant other -Provide breastfeeding education, encouragement, and support -Reinforce positive parenting behaviors

Transition to Extrauterine Life

•Major adaptations - first 6-8 hours after birth •First period of reactivity -Lasts up to 30 minutes after birth -Heart rate increases to 160-180 bpm (and Gradual decrease after 30 min to baseline rate) -Respirations irregular at 60 -80 -infant is alert and may have startles, tremors, crying, head movement -Audible bowel sounds, possible meconium •Period of decreased responsiveness -lasts from 60 to 100 minutes -newborn either sleeps or has a marked decrease in motor activity -Infant is pink -Respirations rapid and shallow but unlabored -Audible bowel sounds •Second period of reactivity -Occurs 2 to 8 hours after birth -Lasts from 10 minutes to several hours -Tachycardia, tachypnea occur -Increased muscle tone -Improved skin color -Mucous production -Meconium typically passed Extremely and very preterm infants do not experience this phase (second period of reactivity) due to physiologic immaturity; they stay in the period of decreased responsiveness.

Postpartum Infections

•May occur during the first 10 days after delivery (most of the time it will be once mom goes home so we need to tell her what to look for) •Predisposing factors: -Concurrent medical conditions (such as anemia or if diabetic or even obesity), immunosuppressive conditions •Intrapartum factors: -C-section (they have a much better risk of developing an infection), operative vaginal delivery (such as using forceps), prolonged ROM, prolonged labor, internal monitoring, multiple exams after ROM, bladder catheterization, episiotomy/laceration Types of postpartum infections: Endometritis: most common PP infection -Begins as an infection at the placental site (bc remember it is a raw site that has to heal) that can spread throughout endometrium and can affect the entire uterus. ▫Symptoms: uterine tenderness, foul-smelling lochia, increased lochia (or darker red still several days later), pelvic pain, vital sign changes (fever, increased HR, increased WBC count), flu-like symptoms (fever, chills, malaise) -Treatment: it is really just supportive care; broad spectrum antibiotics, promote rest, support, pain meds, •Wound infections: -Can occur at Cesarean site - and why we give Ancef before a c section (esp. if obese) or episiotomy/ laceration site (bc it is still a break in skin integrity) -Symptoms: fever, redness, swelling, warmth, tenderness, pain, purulent drainage, wound separation -Treatment: antibiotics, patient may need an I&D, dressing changes. and we would continue to assess for signs of improvement.

Postpartum Period

•Postpartum period is the period of time between birth and when the reproductive organs return to their normal, pre-pregnancy state •Traditionally last about 6 weeks (some of the changes kind of resolve themselves more quickly and some other changes take several weeks to get back to normal)

Bladder

•Preventing bladder distention (so that we don't have a bleeding problem) -Empty bladder spontaneously ASAP after delivery (patients are given 6-8hours after the anesthesia wears off; we would love if they pee before 6 hours. For some women it takes longer bc if they were anesthetized, numbed, a stronger epidural, a lot of swelling around the urethra that can make it really hard to pee, or there has been a foley in mom for several hours and take it longer to pee after the first time.) -If our patient can't pee and has been trying, a nurse intervention we can do is run water, or use a peri bottle on the perineum and that could help. The next thing we would do is straight cath her to empty the bladder for her, again to prevent bleeding.

Why do we give Rhogam?

•Rh-negative woman carries an Rh-positive fetus •Prevents the mother's system from producing anti-Rh-positive antibodies -An Rh- mom and an Rh+ dad make a baby (and bc it is genetics, the baby could have either). We talked about how the placental membrane is so thin so during pregnancy mom and babies blood should never mix, but during delivery, there is the potential for fetus blood cells to entering moms and their blood mixes. Her immune system recognizes these Rh+ cells and her immune system starts to produce antibodies against these Rh+ cells. This first exposure will not be a strong response, but if mom gets pregnant in the future with another Rh+ baby, her immune system will recognize the Rh+ cells again and it can attack the future fetuses red blood cells and causes lysis, and this all can happen in utero to a baby and can cause IUFD bc hemolytic anemia can occur for the baby. This rarely happens anymore bc we give Rhogam to prevent that from happening. Rh sensitization insubsequent pregnancies •Rh antibodies cross the placenta and enter the fetal circulation •Red blood cells of the fetus are attacked by the mother's anti-Rh-positive antibodies, causing hemolysis of fetal red blood cells •Anemia in fetus may result as well as jaundice •Severe hemolytic syndrome - erythroblastosis fetalis Prevention •Administration of Rh immune globulin /Rhogam -all Rh(-) women at 28 weeks gestation (bc we don't know babies blood type) -Rh(-) woman who has miscarriage, ectopic, abdominal trauma such as a car wreck or fell, etc.---anything that could leak fetal cells into mom's blood (these can all precipitate babies fetal cells can mix with maternal blood cells) so if this happens, we also give Rhogam at that time too. -Rh(-) woman who gives birth to Rh+ baby --> Must be given within 72 hours of birth (all babies born to an Rh- mom will be blood typed) - mom does not need Rhogam is both mom and baby are Rh-. (so it is possible that she got it at 28 weeks and then the baby gets out at and is Rh- also and will not need Rhogam again after birth.) -The Rh shot (can be IM or IV) causes lysis of any Rh+ cells that combined. Postpartum Care of the Rh- mother: •Administer Rhogam to Rh- woman who has given birth to Rh + infant -Adverse effects: pain at injection site, headache, myalgia, lethargy, malaise, mild fever (can kind of ccause mild flulike symptoms) -Route and dose: 300mcg IM or IV within 72 hrs of delivery

Health Promotion for Future Pregnancies

•Rubella (MMR vaccine): i rubella non immune, we will go ahead and give an MMR vaccine, to also protect the future pregnancies. MMR is a live vaccine, so we need to tell mom to not get pregnant (they need to wait a bare minimum of 28 days or 4 weeks before getting pregnant). It is safe •Varicella: chicken pox; protecting future pregnancy by giving it to her now. It is a live vaccine so again, do not get pregnant for a month. Safe to breastfeed •Tdap: tetanus booster, --, and pertussis so we use this to boost mom and protect her infant from pertussis. It is offered around 28 weeks but if she did not give it then, then we can give it postpartum. There is really no rules for Tdap bc it is not a live vaccine. •Rhogam: given to Rh - moms postpartum who have had an Rh + baby and we give it within 72 hours of delivery. -a big chunk of women only get medical care when they are pregnant. So with some, patients, this is our time to help promote health and get them up to date on their vaccines, etc.

Vital Signs

•Table 21.1- Signs of potential complications •Temperature ▫May see transient elevation up to 100.4°F due to dehydration from labor for up to 24 hours. (we just need to push oral fluids and can typically fix this low grade fever) -we watch this bc when temp rises, and if we have a temp at 48 or 72 hours, then we would worry and think infection. •HR: we know it went up right after delivery, but should gradually go down to pre-pregnancy baseline. -If she is tachycardia, it could mean we have an infection, hemorrhage, pain, fever, dehydration and fluid volume deficit can all cause this HR to stay up. •BP ▫Orthostatic hypotension (women are very prone to this the first couple days after delivery due to the fluid shift, and so we need to make sure we are doing our safety precautions when mom is getting up) -if we see a pretty significant decreased in the BP r/t bleeding is a pretty late sign and means it has gotten pretty bad and significant. So it is a late sign of a hemorrhage (we would see other signs first like tachycardia, lightheadedness) -If the BP has significantly gone up (above 140/90), we would think preeclampsia